MEDICAL  EDUCATION 

IN  THE 
UNITED  STATES  AND  CANADA// 

A  REPORT  TO 

(THE  CARNEGIE  FOUNDATION 
FOR  THE  ADVANCEMENT  OF  TEACHING.  8cA-W-  "* 


ABRAHAM  FLEXNER 


WITH  AN  INTRODUCTION  BY 

HENRY  S.  PRITCHETT 

PRESIDENT  OF  THE  FOUNDATION 


BULLETIN  NUMBER  FOUR 


576  FIFTH  AVENUE 
NEW  YORK  CITY 


COPYRIGHT  1910 

BY 

THE  CARNEGIE  FOUNDATION 
FOR  THE  ADVANCEMENT  OF  TEACHING 


D.  B.  UPDIKE,  THE  MERRYMOUNT  PRESS,  BOSTON 


Library 


TABLE  OF  CONTENTS 

PAGE 

Introduction      .  vii 


PART  I 

CHAPTER 

I.    Historical  and  General 8 

II.   The  Proper  Basis  of  Medical  Education .20 

III.  The  Actual  Basis  of  Medical  Education 28 

IV.  The  Course  of  Study :  The  Laboratory  Branches.  (A)  First  and  Second 

Years 52 

V.   The  Course  of  Study:  The  Laboratory  Branches.  (B)  First  and  Second 

Years  (continued)  .........  71 

VI.   The  Course  of  Study :  The  Hospital  and  the  Medical  School.  (A)  Third 

and  Fourth  Years 91 

VH.   The  Course  of  Study :  The  Hospital  and  the  Medical  School.  (B)  Third 

and  Fourth  Years  (continued)          .         .         .         .         .         .  105 

VIII.  The  Financial  Aspects  of  Medical  Education 126 

IX.  Reconstruction  .  .  . 143 

X.  Medical  Sects .  .  156 

XL  The  State  Boards •.  .  167 

XII.   The  Postgraduate  School .         .  174 

XIII.  The  Medical  Education  of  Women 178 

XIV.  The  Medical  Education  of  the  Negro     ' 180 

PART  II 
The  Medical  Schools  of 

Alabama 185 

Arkansas       ............  187 

California 188 

Colorado 197 

Connecticut 199 

District  of  Columbia  201 


iv  CONTENTS 

Georgia 203 

Illinois 207 

Indiana 220 

Iowa      .............  222 

Kansas       .         .         .         .         .         ..         .         .         .         .         .  225 

Kentucky 229 

Louisiana 231 

Maine 233 

Maryland          .                 234 

Massachusetts 239 

Michigan 243 

Minnesota 247 

Mississippi 249 

Missouri        ............  251 

Nebraska 259 

New  England 261 

New  Hampshire 263 

New  York 265 

North  Carolina 279 

North  Dakota 282 

Ohio 283 

Oklahoma 289 

Oregon 291 

Pennsylvania 293 

South  Carolina 300 

South  Dakota 301 

Tennessee 302 

Texas 309 

Utah 313 

Vermont 313 

Virginia 314 


CONTENTS  v 

West  Virginia 317 

Wisconsin 317 

Canada 320 

APPENDIX 

Table  showing  number  in  Faculty,  Enrolment,  Fee  Income,  Budget  of  Schools 

by  States 327 


INDEX 337 


INTRODUCTION 

THE  present  report  on  medical  education  forms  the  first  of  a  series  of  papers  on  pro- 
fessional schools  to  be  issued  by  the  Carnegie  Foundation.  The  preparation  of  these 
papers  has  grown  naturally  out  of  the  situation  with  which  the  trustees  of  the  Founda- 
tion were  confronted  when  they  took  up  the  trust  committed  to  them. 

When  the  work  of  the  Foundation  began  five  years  ago  the  trustees  found  them- 
selves intrusted  with  an  endowment  to  be  expended  for  the  benefit  of  teachers  in 
the  colleges  and  universities  of  the  United  States,  Canada,  and  Newfoundland.  It 
required  but  the  briefest  examination  to  show  that  amongst  the  thousand  institu- 
tions in  English-speaking  North  America  which  bore  the  name  college  or  university 
there  was  little  unity  of  purpose  or  of  standards.  A  large  majority  of  all  the  insti- 
tutions in  the  United  States  bearing  the  name  college  were  really  concerned  with 
secondary  education. 

Under  these  conditions  the  trustees  felt  themselves  compelled  to  begin  a  critical 
study  of  the  work  of  the  college  and  of  the  university  in  different  parts  of  this  wide 
area,  and  to  commend  to  colleges  and  universities  the  adoption  of  such  standards  as 
would  intelligently  relate  the  college  to  the  secondary  school  and  to  the  university. 
While  the  Foundation  has  carefully  refrained  from  attempting  to  become  a  stan- 
dardizing agency,  its  influence  has  been  thrown  in  the  direction  of  a  differentiation 
between  the  secondary  school  and  the  college,  and  between  the  college  and  the  uni- 
versity. It  is  indeed  only  one  of  a  number  of  agencies,  including  the  stronger  colleges 
and  universities,  seeking  to  bring  about  in  American  education  some  fair  conception 
of  unity  and  the  attainment  ultimately  of  a  system  of  schools  intelligently  related 
to  each  other  and  to  the  ambitions  and  needs  of  a  democracy. 

At  the  beginning,  the  Foundation  naturally  turned  its  study  to  the  college,  as 
that  part  of  our  educational  system  most  directly  to  be  benefited  by  its  endowment. 
Inevitably,  however,  the  scrutiny  of  the  college  led  to  the  consideration  of  the  re- 
lations between  the  college  or  university  and  the  professional  schools  which  had 
gathered  about  it  or  were  included  in  it.  The  confusion  found  here  was  quite  as  great  as 
that  which  exists  between  the  field  of  the  college  and  that  of  the  secondary  school.  Col- 1 
leges  and  universities  were  discovered  to  have  all  sorts  of  relations  to  their  professional  \ 
schools  of  law,  of  medicine,  and  of  theology.  In  some  cases  these  relations  were  of  the 
frailest  texture,  constituting  practically  only  a  license  from  the  college  by  which  a 
proprietary  p^ipal  gffrnnl  9^  lavy  school  was  enabled  to  live  under  its  name.  In  other 
cases  the  medical  school  was  incorporated  into  the  college  or  university,  but  remained 
an  imperium  in  imperio,  the  college  assuming  no  responsibility  for  its  standards  or 
its  support.  In  yet  other  cases  the  college  or  university  assumed  partial  obligation  of 
support,  but  no  responsibility  for  the  standards  of  the  professional  school,  while  in 
only  a  relatively  small  number  of  cases  was  the  school  of  law  or  of  medicine  an  in- 
tegral part  of  the  university,  receiving  from  it  university  standards  and  adequate 


viii  INTRODUCTION 

maintenance.  For  the  past  two  decades  there  has  been  a  marked  tendency  to  set  up 
some  connection  between  universities  and  detached  medical  schools,  but  under  the 
very  loose  construction  just  referred  to. 

Meanwhile  the  requirements  of  medical  education  have  enormously  increased.  The 
fundamental  sciences  upon  which  medicine  depends  have  been  greatly  extended. 
The  laboratory  has  come  to  furnish  alike  to  the  physician  and  to  the  surgeon  a  new 
means  for  diagnosing  and  combating  disease.  The  education  of  the  medical  practi- 
tioner under  these  changed  conditions  makes  entirely  different  demands  in  respect  to 
both  preliminary  and  professional  training. 

Under  these  conditions  and  in  the  face  of  the  advancing  standards  of  the  best 
medical  schools  it  was  clear  that  the  time  had  come  when  the  relation  of  professional 
education  in  medicine  to  the  general  system  of  education  should  be  clearly  defined. 
The  first  step  towards  such  a  clear  understanding  was  to  ascertain  the  facts  concern- 
ing medical  education  and  the  medical  schools  themselves  at  the  present  time.  In  ac- 
cordance, therefore,  with  the  recommendation  of  the  president  and  the  executive  com- 
mittee, the  trustees  of  the  Carnegie  Foundation  at  their  meeting  in  November,  1908, 
authorized  a  study  and  report  upon  the  schools  of  medicine  and  law  in  the  United 
States  and  appropriated  the  money  necessary  for  this  undertaking.  The  present  report 
upon  medical  education,  prepared,  under  the  direction  of  the  Foundation,  by  Mr. 
Abraham  Flexner,  is  the  first  result  of  that  action. 

No  effort  has  been  spared  to  procure  accurate  and  detailed  information  as  to  the 
facilities,  resources,  and  methods  of  instruction  of  the  medical  schools.  They  have 
not  only  been  separately  visited,  but  every  statement  made  in  regard  to  each  detail 
has  been  carefully  checked  with  the  data  in  possession  of  the  American  Medical  Asso- 
ciation, likewise  obtained  by  personal  inspection,  and  with  the  records  of  the  Asso- 
ciation of  American  Medical  Colleges,  so  far  as  its  membership  extends.  The  details 
as  stated  go  forth  with  the  sanction  of  at  least  two,  and  frequently  more,  independent 
observers. 

In  making  this  study  the  schools  of  all  medical  sects  have  been  included.  It  is  clear 
that  so  long  as  a  man  is  to  practise  medicine,  the  public  is  equally  concerned  in  his 
right  preparation  for  that  profession,  whatever  he  call  himself, — allopath,  homeo- 
path, eclectic,  osteopath,  or  whatnot.  It  is  equally  clear  that  he  should  be  grounded 
in  the  fundamental  sciences  upon  which  medicine  rests,  whether  he  practises  under 
one  name  or  under  another. 

It  will  be  readily  understood  that  the  labor  involved  in  visiting  150  such  schools 
is  great,  and  that  in  the  immense  number  of  details  dealt  with  it  is  altogether  im- 
possible to  be  sure  that  every  minute  fact  concerning  these  institutions  has  been 
ascertained  and  set  down.  While  the  Foundation  cannot  hope  to  obtain  in  so  great 
an  undertaking  absolute  completeness  in  every  particular,  such  care  has  been  exer- 
cised, and  the  work  has  been  so  thoroughly  reviewed  by  independent  authorities, 
that  the  statements  which  are  given  here  may  be  confidently  accepted  as  setting 


INTRODUCTION  ix 

forth  the  essential  facts  respecting  medical  education  and  respecting  the  institutions 
which  deal  with  it. 

In  this  connection  it  is  perhaps  desirable  to  add  one  further  word.  Educational 
institutions,  particularly  those  which  are  connected  with  a  college  or  a  university, 
are  peculiarly  sensitive  to  outside  criticism,  and  particularly  to  any  statement  of 
the  circumstances  of  their  own  conduct  or  equipment  which  seems  to  them  unfavor- 
able in  comparison  with  that  of  other  institutions.  As  a  rule,  the  only  knowledge 
which  the  public  has  concerning  an  institution  of  learning  is  derived  from  the  state- 
ments given  out  by  the  institution  itself,  information  which,  even  under  the  best  cir- 
cumstances, is  colored  by  local  hopes,  ambitions,  and  points  of  view.  A  considerable 
number  of  colleges  and  universities  take  the  unfortunate  position  that  they  are  private 
institutions  and  that  the  public  is  entitled  to  only  such  knowledge  of  their  operations 
as  they  choose  to  communicate.  In  the  case  of  many  medical  schools  the  aversion  to 
publicity  is  quite  as  marked  as  it  is  reputed  to  be  in  the  case  of  certain  large  indus- 
trial trusts.  A  few  institutions  questioned  the  right  of  any  outside  agency  to  collect  and 
publish  the  facts  concerning  their  medical  schools.  The  Foundation  was  called  upon  to 
answer  the  question :  Shall  such  an  agency  as  the  Foundation,  dedicated  to  the  bet- 
terment of  American  education,  make  public  the  facts  concerning  the  medical  schools 
of  the  United  States  and  Canada? 

The  attitude  of  the  Foundation  is  that  all  colleges  and  universities,  whether  sup- 
ported by  taxation  or  by  private  endowment,  are  in  truth  public  service  corporations, 
and  that  the  public  is  entitled  to  know  the  facts  concerning  their  administration  and 
development,  whether  those  facts  pertain  to  the  financial  or  to  the  educational  side. 
We  believe,  therefore,  that  in  seeking  to  present  an  accurate  and  fair  statement  of 
the  work  and  the  facilities  of  the  medical  schools  of  this  country,  we  are  serving  the 
best  possible  purpose  which  such  an  agency  as  the  Foundation  can  serve;  and,  further- 
more, that  only  by  such  publicity  can  the  true  interests  of  education  and  of  the 
uni versities  themselves  be  subserved.  In  such  a  reasonable  publicity  lies  the  hope 
for  progress  in  medical  education. 

I  wish  to  add  with  pleasure  that  notwithstanding  reluctance  in  some  quarters  to 
furnish  information,  the  medical  schools  of  the  colleges  and  universities,  as  well 
as  proprietary  and  independent  medical  schools,  have  generally  accepted  the  view 
just  stated  and  have  seconded  the  work  of  the  Foundation  by  offering  to  those  who 
were  engaged  in  this  study  every  facility  to  learn  their  opportunities  and  resources; 
and  I  beg  to  express  the  thanks  of  the  trustees  of  the  Foundation  to  each  of  these 
institutions  for  the  cooperation  which  it  has  given  to  a  study  which,  in  the  very  nature 
of  the  case,  was  to  bear  sharply  in  the  way  of  criticism  upon  many  of  those  called 
on  for  cooperation. 

The  report  which  follows  is  divided  into  two  parts.  In  the  first  half  the  history  of 
medical  education  in  this  country  and  its  present  status  are  set  forth.  The  story  is 
there  told  of  the  gradual  development  of  the  commercial  medical  school,  distinctly 


x  INTRODUCTION 

an  American  product,  of  the  mo4ern  movement  for  the  transfer  of  medical  education 
to  university  surroundings,  and  of  the  effort  to  procure  stricter  scrutiny  of  those  seek- 
ing to  enter  the  profession.  The  present  status  of  medical  education  is  then  fully 
described  and  a  forecast  of  possible  progress  in  the  future  is  attempted.  The  second 
part  of  the  report  gives  in  detail  a  description  of  the  schools  in  existence  in  each 
state  of  the  Union  and  in  each  province  of  Canada. 

It  is  the  purpose  of  the  Foundation  to  proceed  at  once  with  a  similar  study  of  medi- 
cal education  in  Great  Britain,  Germany,  and  France,  in  order  that  those  charged 
with  the  reconstruction  of  medical  education  in  America  may  profit  by  the  experi- 
ence of  other  countries. 

The  striking  and  significant  facts  which  are  here  brought  out  are  of  enormous  con- 
sequence not  only  to  the  medical  practitioner,  but  to  every  citizen  of  the  United 
States  and  Canada;  for  it  is  a  singular  fact  that  the  organization  of  medical  educa- 
tion in  this  country  has  hitherto  been  such  as  not  only  to  commercialize  the  process 
of  education  itself,  but  also  to  obscure  in  the  minds  of  the  public  any  discrimination 
between  the  well  trained  physician  and  the  physician  who  has  had  no  adequate  train- 
ing whatsoever.  As  a  rule,  Americans,  when  they  avail  themselves  of  the  services  of 
a  physician,  make  only  the  slightest  inquiry  as  to  what  his  previous  training  and 
preparation  have  been.  One  of  the  problems  of  the  future  is  to  educate  the  public 
itself  to  appreciate  the  fact  that  very  seldom,  under  existing  conditions,  does  a  patient 
receive  the  best  aid  which  it  is  possible  to  give  him  in  the  present  state  of  medicine, 
and  that  this  is  due  mainly  to  the  fact  that  a  vast  army  of  men  is  admitted  to  the 
practice  of  medicine  who  are  untrained  in  sciences  fundamental  to  the  profession  and 
quite  without  a  sufficient  experience  with  disease.  A  right  education  of  public  opinion 
is  one  of  the  problems  of  future  medical  education. 

The  significant  facts  revealed  by  this  study  are  these: 

(1)  For  twenty-five  years  past  there  has  been  an  enormous  over-production  of  un- 
educated and  ill  trained  medical  practitioners.  This  has  been  in  absolute  disregard 
of  the  public  welfare  and  without  any  serious  thought  of  the  interests  of  the  public. 
Taking  the  United  States  as  a  whole,  physicians  are  four  or  five  times  as  numerous  in 
proportion  to  population  as  in  older  countries  like  Germany. 

(2)  Over-production  of  ill  trained  men  is  due  in  the  main  to  the  existence  of  a 
very  large  number  of  commercial  schools,  sustained  in  many  cases  by  advertising 
methods  through  which  a  mass  of  unprepared  youth  is  drawn  out  of  industrial  occu- 
pations into  the  study  of  medicine. 

(3)  Until  recently  the  conduct  of  a  medical  school  was  a  profitable  business,  for 
the  methods  of  instruction  were  mainly  didactic.  As  the  need  for  laboratories  has  be- 
come more  keenly  felt,  the  expenses  of  an  efficient  medical  school  have  been  greatly 
increased.  The  inadequacy  of  many  of  these  schools  may  be  judged  from  the  fact  that 
nearly  half  of  all  our  medical  schools  have  incomes  below  $10,000,  and  these  incomes 
determine  the  quality  of  instruction  that  they  can  and  do  offer. 


INTRODUCTION  xi 

Colleges  and  universities  have  in  large  measure  failed  in  the  past  twenty-five  years 
to  appreciate  the  great  advance  in  medical  education  and  the  increased  cost  of  teach- 
ing it  along  modern  lines.  Many  universities  desirous  of  apparent  educational  com- 
pleteness have  annexed  medical  schools  without  making  themselves  responsible  either 
for  the  standards  of  the  professional  schools  or  for  their  support. 

(4)  The  existence  of  many  of  these  unnecessary  and  inadequate  medical  schools  has 
been  defended  by  the  argument  that  a  poor  medical  school  is  justified  in  the  interest 
of  the  poor  boy.  It  is  clear  that  the  poor  boy  has  no  right  to  go  into  any  profession 
for  which  he  is  not  willing  to  obtain  adequate  preparation;  but  the  facts  set  forth  in 
this  report  make  it  evident  that  this  argument  is  insincere,  and  that  the  excuse 
which  has  hitherto  been  put  forward  in  the  name  of  the  poor  boy  is  in  reality  an  ar- 
gument in  behalf  of  the  poor  medical  school. 

(5)  A  hospital  under  complete  educational  control  is  as  necessary  to  a  medical  school 
as  is  a  laboratory  of  chemistry  or  pathology.  High  grade  teaching  within  a  hospital 
introduces  a  most  wholesome  and  beneficial  influence  into  its  routine.  Trustees  of  hos- 
pitals, public  and  private,  should  therefore  go  to  the  limit  of  their  authority  in  open- 
ing hospital  wards  to  teaching,  provided  only  that  the  universities  secure  sufficient 
funds  on  their  side  to  employ  as  teachers  men  who  are  devoted  to  clinical  science. 

In  view  of  these  facts,  progress  for  the  future  would  seem  to  require  a  very  much 
smaller  number  of  medical  schools,  better  equipped  and  better  conducted  than  our 
schools  now  as  a  rule  are;  and  the  needs  of  the  public  would  equally  require  that  we 
have  fewer  physicians  graduated  each  year,  but  that  these  should  be  better  educated 
and  better  trained.  With  this  idea  accepted,  it  necessarily  follows  that  the  medical 
school  will,  if  rightly  conducted,  articulate  not  only  with  the  university,  but  with 
the  general  system  of  education.  Just  what  form  that  articulation  must  take  will 
vary  in  the  immediate  future  in  different  parts  of  the  country.  Throughout  the  east- 
ern and  central  states  the  movement  under  which  the  medical  school  articulates  with 
the  second  year  of  the  college  has  already  gained  such  impetus  that  it  can  be  regarded 
as  practically  accepted.  In  the  southern  states  for  the  present  it  would  seem  that 
articulation  with  the  four-year  high  school  would  be  a  reasonable  starting-point  for 
the  future.  In  time  the  development  of  secondary  education  in  the  south  and  the 
growth  of  the  colleges  will  make  it  possible  for  southern  medical  schools  to  accept 
the  two-year  college  basis  of  preparation.  With  reasonable  prophecy  the  time  is  not 
far  distant  when,  with  fair  respect  for  the  interests  of  the  public  and  the  need  for 
physicians,  the  articulation  of  the  medical  school  with  the  university  may  be  the 
same  throughout  the  entire  country.  For  in  the  future  the  college  or  the  university 
which  accepts  a  medical  school  must  make  itself  responsible  for  university  standards 
in  the  medical  school  and  for  adequate  support  for  medical  education.  The  day  has 
gone  by  when  any  university  can  retain  the  respect  of  educated  men,  or  when  it  can 
fulfil  its  duty  to  education,  by  retaining  a  low  grade  professional  school  for  the  sake 
of  its  own  institutional  completeness. 


xii  INTRODUCTION 

If  these  fundamental  principles  can  be  made  clear  to  the  people  of  the  United 
States  and  of  Canada,  and  to  those  who  govern  the  colleges  and  the  universities,  we 
may  confidently  expect  that  the  next  ten  years  will  see  a  very  much  smaller  number 
of  medical  schools  in  this  country,  but  a  greatly  increased  efficiency  in  medical  edu- 
cation, and  that  during  the  same  period  medical  education  will  become  rightly  articu- 
lated with,  and  rightly  related  to,  the  general  educational  system  of  the  whole  country. 

In  the  suggestions  which  are  made  in  this  report  looking  toward  the  future  de- 
velopment of  medicine,  it  ought  to  be  pointed  out  that  no  visionary  or  impossible 
achievement  is  contemplated.  It  is  not  expected  that  a  Johns  Hopkins  Medical  School 
can  be  erected  immediately  in  cities  where  public  support  of  education  has  hitherto 
been  meager.  Nevertheless,  it  is  quite  true  that  there  is  a  certain  minimum  of  equip- 
ment and  a  minimum  of  educational  requirement  without  which  no  attempt  ought 
to  be  made  to  teach  medicine.  Hitherto  not  only  proprietary  medical  schools,  but 
colleges  and  universities,  have  paid  scant  attention  to  this  fact.  They  have  been  ready 
to  assume  the  responsibility  of  turning  loose  upon  a  helpless  community  men  licensed 
to  the  practice  of  medicine  without  any  serious  thought  as  to  whether  they  had  re- 
ceived a  fair  training  or  not.  To-day,  under  the  methods  pursued  in  modern  medi- 
cine, we  know  with  certainty  that  a  medical  school  cannot  be  conducted  without  a 
certain  minimum  of  expense  and  without  a  certain  minimum  of  facilities.  The  insti- 
tution which  attempts  to  conduct  a  school  below  this  plane  is  clearly  injuring,  not 
helping,  civilization.  In  the  suggestions  which  are  made  in  this  report  as  to  what 
constitutes  a  reasonable  minimum  no  visionary  ideal  has  been  pursued,  but  only  such 
things  have  been  insisted  upon  as  in  the  present  light  of  our  American  civilization 
every  community  has  a  right  to  demand  of  its  medical  school,  if  medicine  is  to  be 
taught  at  all. 

It  seems  desirable  also  in  connection  with  both  the  medical  school  and  the  uni- 
versity or  college  to  add  one  word  further  concerning  the  relation  of  financial  sup- 
port to  efficiency  and  sincerity.  Where  any  criticism  is  attempted  of  inadequate 
methods  or  inadequate  facilities,  no  reply  is  more  common  than  this:  "Our  insti- 
tution cannot  be  judged  from  its  financial  support.  It  depends  upon  the  enthusiasm 
and  the  devotion  of  its  teachers  and  its  supporters,  and  such  devotion  cannot  be 
measured  by  financial  standards. " 

Such  an  answer  contains  so  fine  a  sentiment  and  so  pregnant  a  truth  that  it  often- 
times serves  to  turn  aside  the  most  just  criticism.  It  is  true  that  every  college  must 
ultimately  depend  upon  the  spirit  and  devotion  of  those  who  work  in  it,  but  behind 
this  noble  statement  hides  most  of  the  insincerity,  sham,  and  pretense  not  only  of  the 
American  medical  school,  but  of  the  American  college.  The  answer  quoted  is  com- 
monly made  by  the  so-called  university  that,  with  an  income  insufficient  to  support 
a  decent  college,  is  trying  to  cover  the  whole  field  of  university  education.  It  is  the 
same  answer  that  one  receives  from  the  medical  school  which,  with  wholly  inade- 
quate facilities,  is  turning  out  upon  an  innocent  and  long-suffering  community  men 


INTRODUCTION  xiii 

who  must  get  their  medical  education  after  they  get  out  of  the  institution.  In 
many  of  these  ill  manned  and  poorly  equipped  institutions  there  is  to  be  found  a 
large  measure  of  devotion,  but  the  fact  remains  that  such  devotion  is  usually  ill 
placed,  and  the  individual  who  gives  it  loses  sight  of  the  interests  of  education  and 
of  the  general  public  in  his  desire  to  keep  alive  an  institution  without  reason  or 
right  to  exist. 

It  will,  however,  be  urged  by  weak  schools  that  the  fact  that  an  institution  is  ill 
manned  and  poorly  equipped  is  inconclusive;  that  in  the  time  devoted  to  the  ex- 
amination of  a  single  school  it  is  impossible  to  do  it  justice.  Objection  of  this  kind 
is  apt  to  come  from  schools  of  two  types, — ineffective  institutions  in  large  cities, 
and  schools  attached  to  colleges  in  small  towns  in  which  clinical  material  is  scarce. 
In  my  opinion  the  objection  is  without  force.  A  trained  observer  of  wide  experience 
can  go  directly  to  the  heart  of  a  problem  of  this  character.  The  spirit,  ideals,  and 
facilities  of  a  professional  or  technical  school  can  be  quickly  grasped.  In  every  in- 
stance in  which  further  inquiry  has  been  made,  the  conclusions  reached  by  the  au- 
thor of  the  report  have  been  sustained. 

The  development  which  is  here  suggested  for  medical  education  is  conditioned 
largely  upon  three  factors:  first,  upon  the  creation  of  a  public  opinion  which  shall 
discriminate  between  the  ill  trained  and  the  rightly  trained  physician,  and  which  will 
also  insist  upon  the  enactment  of  such  laws  as  will  require  all  practitioners  of  medi- 
cine, whether  they  belong  to  one  sect  or  another,  to  ground  themselves  in  the  funda- 
mentals upon  which  medical  science  rests ;  secondly,  upon  the  universities  and  their 
attitude  towards  medical  standards  and  medical  support;  finally,  upon  the  attitude 
of  the  members  of  the  medical  profession  towards  the  standards  of  their  own  practice 
and  upon  their  sense  of  honor  with  respect  to  their  own  profession. 

These  last  two  factors  are  moral  rather  than  educational.  They  call  for  an  educa- 
tional patriotism  on  the  part  of  the  institutions  of  learning  and  a  medical  patriotism 
on  the  part  of  the  physician. 

By  educational  patriotism  I  mean  this :  a  university  has  a  mission  greater  than  the 
formation  of  a  large  student  body  or  the  attainment  of  institutional  completeness, 
namely,  the  duty  of  loyalty  to  the  standards  of  common  honesty,  of  intellectual  sin- 
cerity, of  scientific  accuracy.  A  university  with  educational  patriotism  will  not  take 
up  the  work  of  medical  education  unless  it  can  discharge  its  duty  by  it;  or  if, 
in  the  days  of  ignorance  once  winked  at,  a  university  became  entangled  in  a  medi- 
cal school  alliance,  it  will  frankly  and  courageously  deal  with  a  situation  which  is 
no  longer  tenable.  It  will  either  demand  of  its  medical  school  university  ideals  and 
give  it  university  support,  or  else  it  will  drop  the  effort  to  do  what  it  can  only  do 
badly. 

By  professional  patriotism  amongst  medical  men  I  mean  that  sort  of  regard  for 
the  honor  of  the  profession  and  that  sense  of  responsibility  for  its  efficiency  which 
will  enable  a  member  of  that  profession  to  rise  above  the  consideration  of  personal 


xiv  INTRODUCTION 

or  of  professional  gain.  As  Bacon  truly  wrote,  "Every  man  owes  a  duty  to  his  pro- 
fession," and  in  no  profession  is  this  obligation  more  clear  than  in  that  of  the  mod- 
ern physician.  Perhaps  in  no  other  of  the  great  professions  does  one  find  greater  dis- 
crepancies between  the  ideals  of  those  who  represent  it.  No  members  of  the  social 
order  are  more  self-sacrificing  than  the  true  physicians  and  surgeons,  and  of  this 
fine  group  none  deserve  so  much  of  society  as  those  who  have  taken  upon  their 
shoulders  the  burden  of  medical  education.  On  the  other  hand,  the  profession  has 
been  diluted  by  the  presence  of  a  great  number  of  men  who  have  come  from  weak 
schools  with  low  ideals  both  of  education  and  of  professional  honor.  If  the  medical 
education  of  our  country  is  in  the  immediate  future  to  go  upon  a  plane  of  efficiency 
and  of  credit,  those  who  represent  the  higher  ideals  of  the  medical  profession  must 
make  a  stand  for  that  form  of  medical  education  which  is  calculated  to  advance  the 
true  interests  of  the  whole  people  and  to  better  the  ideals  of  medicine  itself. 

There  is  raised  in  the  discussion  of  this  question  a  far-reaching  economic  pro- 
blem to  which  society  has  as  yet  given  little  attention ;  that  is  to  say,  What  safeguards 
may  society  and  the  law  throw  about  admission  to  a  profession  like  that  of  law  or 
of  medicine  in  order  that  a  sufficient  number  of  men  may  be  induced  to  enter  it  and 
yet  the  unfit  and  the  undesirable  may  be  excluded? 

It  is  evident  that  in  a  society  constituted  as  are  our  modern  states,  the  interests  of 
the  social  order  will  be  served  best  when  the  number  of  men  entering  a  given  pro- 
fession reaches  and  does  not  exceed  a  certain  ratio.  For  example,  in  law  and  medi- 
cine one  sees  best  in  a  small  village  the  situation  created  by  the  over-production  of 
inadequately  trained  men.  In  a  town  of  two  thousand  people  one  will  find  in  most 
of  our  states  from  five  to  eight  physicians  where  two  well  trained  men  could  do  the 
work  efficiently  and  make  a  competent  livelihood.  When,  however,  six  or  eight  ill 
trained  physicians  undertake  to  gain  a  living  in  a  town  which  can  support  only  two, 
the  whole  plane  of  professional  conduct  is  lowered  in  the  struggle  which  ensues,  each 
man  becomes  intent  upon  his  own  practice,  public  health  and  sanitation  are  neglected, 
and  the  ideals  and  standards  of  the  profession  tend  to  demoralization. 

A  similar  state  of  affairs  comes  from  the  presence  of  too  large  a  number  of  ill 
trained  lawyers  in  a  community.  When  six  or  eight  men  seek  to  gain  their  living  from 
the  practice  of  the  law  in  a  community  in  which,  at  the  most,  two  good  lawyers 
could  do  all  the  work,  the  demoralization  to  society  becomes  acute.  Not  only  is  the 
process  of  the  law  unduly  lengthened,  but  the  temptation  is  great  to  create  busi- 
ness. No  small  proportion  of  the  American  lack  of  respect  for  the  law  grows  out  of 
the  presence  of  this  large  number  of  ill  trained  men  seeking  to  gain  a  livelihood 
from  the  business  which  ought  in  the  nature  of  the  case  to  support  only  a  much 
smaller  number.  It  seems  clear  that  as  nations  advance  in  civilization,  they  will  be 
driven  to  throw  around  the  admission  to  these  great  professions  such  safeguards  as 
will  limit  the  number  of  those  who  enter  them  to  some  reasonable  estimate  of  the 
number  who  are  actually  needed.  It  goes  without  saying  that  no  system  of  stan- 


INTRODUCTION  xv 

dards  of  admission  to  a  profession  can  exclude  all  the  unfit  or  furnish  a  perfect 
body  of  practitioners,  but  a  reasonable  enforcement  of  such  standards  will  at  least 
relieve  the  body  politic  of  a  large  part  of  the  difficulty  which  comes  from  over- 
production, and  will  safeguard  the  right  of  society  to  the  service  of  trained  men  in 
the  great  callings  which  touch  so  closely  our  physical  and  political  life. 

The  object  of  the  Foundation  in  undertaking  studies  of  this  character  is  to  serve 
a  constructive  purpose,  not  a  critical  one.  Unless  the  information  here  brought  to- 
gether leads  to  constructive  work,  it  will  fail  of  its  purpose.  The  very  disappearance 
of  many  existing  schools  is  part  of  the  reconstructive  process.  Indeed,  in  the  course 
of  preparing  the  report  a  number  of  results  have  already  come  about  which  are 
of  the  highest  interest  from  the  constructive  point  of  view.  Several  colleges,  finding 
themselves  unable  to  carry  on  a  medical  school  upon  right  lines,  have,  frankly  facing 
the  situation,  discontinued  their  medical  departments,  the  result  being  a  real  gain  to 
medical  education.  Elsewhere,  competing  medical  schools  which  were  dividing  the  stu- 
dents and  the  hospital  facilities  have  united  into  a  single  school.  In  still  other  instances 
large  sums  of  money  have  been  raised  to  place  medical  education  on  a  firmer  basis. 

In  the  preparation  of  this  report  the  Foundation  has  kept  steadily  in  view  the 
interests  of  two  classes,  which  in  the  over-multiplication  of  medical  schools  have 
usually  been  forgotten, —  first,  the  youths  who  are  to  study  medicine  and  to  become 
the  future  practitioners,  and,  secondly,  the  general  public,  which  is  to  live  and  die 
under  their  ministrations. 

No  one  can  become  familiar  with  this  situation  without  acquiring  a  hearty  sym- 
pathy for  the  American  youth  who,  too  often  the  prey  of  commercial  advertising 
methods,  is  steered  into  the  practice  of  medicine  with  almost  no  opportunity  to 
learn  the  difference  between  an  efficient  medical  school  and  a  hopelessly  inadequate 
one.  A  clerk  who  is  receiving  $50  a  month  in  the  country  store  gets  an  alluring 
brochure  which  paints  the  life  of  the  physician  as  an  easy  road  to  wealth.  He  has 
no  realization  of  the  difference  between  medicine  as  a  profession  and  medicine  as  a 
business,  nor  as  a  rule  has  he  any  adviser  at  hand  to  show  him  that  the  first  requi- 
site for  the  modern  practitioner  of  medicine  is  a  good  general  education.  Such  a  boy 
falls  an  easy  victim  to  the  commercial  medical  school,  whether  operating  under  the 
name  of  a  university  or  college,  or  alone. 

The  interests  of  the  general  public  have  been  so  generally  lost  sight  of  in  this 
matter  that  the  public  has  in  large  measure  forgot  that  it  has  any  interests  to  pro- 
tect. And  yet  in  no  other  way  does  education  more  closely  touch  the  individual  than 
in  the  quality  of  medical  training  which  the  institutions  of  the  country  provide. 
Not  only  the  personal  well-being  of  each  citizen,  but  national,  state,  and  municipal 
sanitation  rests  upon  the  quality  of  the  training  which  the  medical  graduate  has  re- 
ceived. The  interest  of  the  public  is  to  have  well  trained  practitioners  in  sufficient 
number  for  the  needs  of  society.  The  source  whence  these  practitioners  are  to  come 
is  of  far  less  consequence. 


xvi  INTRODUCTION 

In  view  of  this  fact,  the  argument  advanced  for  the  retention  of  medical  schools  in 
places  where  good  clinical  instruction  is  impossible  is  directly  against  the  public 
interest.  If  the  argument  were  valid,  it  would  mean  that  the  sick  man  is  better  off 
in  the  hands  of  an  incompetent  home-grown  practitioner  than  in  those  of  one  well 
trained  in  an  outside  school.  Such  an  argument  ought  no  longer  to  blind  the  eyes 
of  intelligent  men  to  the  actual  situation.  Any  state  of  the  Union  or  any  province 
of  Canada  is  better  off  without  a  medical  school  than  with  one  conducted  in  a  com- 
mercial spirit  and  below  a  reasonable  plane  of  efficiency.  No  state  and  no  section  of 
a  state  capable  of  supporting  a  good  practitioner  will  suffer  by  following  this  policy. 
The  state  of  Washington,  which  has  no  medical  school  within  its  borders,  is  doubt- 
less supplied  with  as  capable  and  well  trained  a  body  of  medical  practitioners  as  is 
Missouri  with  its  eleven  medical  schools  or  Illinois  with  its  fourteen. 

The  point  of  view  which  keeps  in  mind  the  needs  and  qualifications  of  the  medi- 
cal student  and  the  interests  of  the  great  public  is  quite  a  different  one  from  that 
which  the  institution  which  conducts  a  medical  department  ordinarily  occupies.  The 
questions  which  look  largest  to  the  institutions  are :  Can  we  add  a  medical  school  to 
our  other  departments?  and  if  so,  where  can  we  find  the  students?  The  questions 
which  the  other  point  of  view  suggest  are :  Is  a  medical  school  needed  ?  Cannot  those 
qualified  to  study  medicine  find  opportunities  in  existing  schools?  If  not,  are  the 
means  and  the  facilities  at  hand  for  teaching  medicine  on  a  right  basis? 

While  the  aim  of  the  Foundation  has  throughout  been  constructive,  its  attitude 
towards  the  difficulties  and  problems  of  the  situation  is  distinctly  sympathetic.  The 
report  indeed  turns  the  light  upon  conditions  which,  instead  of  being  fruitful  and 
inspiring,  are  in  many  instances  commonplace,  in  other  places  bad,  and  in  still  others, 
scandalous.  It  is  nevertheless  true  that  no  one  set  of  men  or  no  one  school  of  medi- 
cine is  responsible  for  what  still  remains  in  the  form  of  commercial  medical  educa- 
tion. Our  hope  is  that  this  report  will  make  plain  once  for  all  that  the  day  of  the 
commercial  medical  school  has  passed.  It  will  be  observed  that,  except  for  a  brief  his- 
torical introduction,  intended  to  show  how  present  conditions  have  come  about,  no 
account  is  given  of  the  past  of  any  institution.  The  situation  is  described  as  it  exists  to- 
day in  the  hope  that  out  of  it,  quite  regardless  of  the  past,  a  new  order  may  be  speedily 
developed.  There  is  no  need  now  of  recriminations  over  what  has  been,  or  of  apolo- 
gies by  way  of  defending  a  regime  practically  obsolete.  Let  us  address  ourselves  re- 
solutely to  the  task  of  reconstructing  the  American  medical  school  on  the  lines  of  the 
highest  modern  ideals  of  efficiency  and  in  accordance  with  the  finest  conceptions  of 
public  service. 

It  is  hoped  that  both  the  purpose  of  the  Foundation  and  its  point  of  view  as  thus 
stated  may  be  remembered  in  any  consideration  of  the  report  which  follows,  and  that 
this  publication  may  serve  as  a  starting-point  both  for  the  intelligent  citizen  and  for 
the  medical  practitioner  in  a  new  national  effort  to  strengthen  the  medical  profession 
and  rightly  to  relate  medical  education  to  the  general  system  of  schools  of  our  nation. 


INTRODUCTION  xvii 

The  Foundation  is  under  the  greatest  obligation  in  the  preparation  of  this  report 
to  leading  representatives  of  medicine  and  surgery  in  this  country  for  their  coopera- 
tion and  advice.  The  officers  of  the  various  medical  associations  and  of  the  Associa- 
tion of  American  Medical  Colleges  have  furnished  information  which  was  invaluable 
and  have  given  aid  in  the  most  cordial  way.  We  are  particularly  indebted  for  con- 
stant and  generous  assistance  to  Dr.  William  H.  Welch  of  Johns  Hopkins  Uni- 
versity, Dr.  Simon  Flexner  of  the  Rockefeller  Institute,  and  Dr.  Arthur  D.  Bevan, 
chairman  of  the  Council  on  Education  of  the  American  Medical  Association.  In  ad- 
dition, our  acknowledgments  are  due  to  Dr.  N.  P.  Colwell,  secretary  of  the  Council  on 
Education  of  the  American  Medical  Association,  and  to  Dr.  F.  C.  Zapffe,  secretary 
of  the  Association  of  American  Medical  Colleges,  for  most  helpful  cooperation.  I  wish 
to  acknowledge  also  our  indebtedness  to  a  number  of  eminent  men  connected  with 
various  schools  of  medicine  who  have  been  kind  enough  to  read  the  proof  of  this 
report  and  to  give  us  the  benefit  of  their  comment  and  criticism. 

HENRY  S.  PRITCHETT. 
April  16, 1910. 


PART  I 
MEDICAL  EDUCATION 

IN  THE  UNITED  STATES  AND  CANADA 


CHAPTER  I 

HISTORICAL  AND  GENERAL 

THE  American  medical  school  is  now  well  along  in  the  second  century  of  its  history.1 
It  began,  and  for  many  years  continued  to  exist,  as  a  supplement  to  the  apprentice- 
ship system  still  in  vogue  during  the  seventeenth  and  eighteenth  centuries.  The 
likely  youth  of  that  period,  destined  to  a  medical  career,  was  at  an  early  age  inden- 
tured to  some  reputable  practitioner;  to  whom  his  service  was  successively  menial, 
pharmaceutical,  and  professional:  he  ran  his  master's  errands,  washed  the  bottles, 
mixed  the  drugs,  spread  the  plasters,  and  finally,  as  the  stipulated  term  drew  towards 
its  close,  actually  took  part  in  the  daily  practice  of  his  preceptor, — bleeding  his 
patients,  pulling  their  teeth,  and  obeying  a  hurried  summons  in  the  night.  The 
quality  of  the  training  varied  within  large  limits  with  the  capacity  and  conscientious- 
ness of  the  master.  Ambitious  spirits  sought,  therefore,  a  more  assured  and  inspiring 
discipline.  Beginning  early  in  the  eighteenth  century,  having  served  their  time  at 
home,  they  resorted  in  rapidly  increasing  numbers  to  the  hospitals  and  lecture-halls 
of  Leyden,  Paris,  London,  and  Edinburgh.  The  difficulty  of  the  undertaking  proved 
admirably  selective ;  for  the  students  who  crossed  the  Atlantic  gave  a  good  account 
of  themselves.  Returning  to  their  native  land,  they  sought  opportunities  to  share 
with  their  less  fortunate  or  less  adventurous  fellows  the  rich  experience  gained  as 
they  "walked  the  hospitals"  of  the  old  world  in  the  footsteps  of  Cullen,  Munro,  and 
the  Hunters.  The  voices  of  the  great  masters  of  that  day  thus  reechoed  in  the  recent 
western  wilderness.  High  scientific  and  professional  ideals  impelled  the  youthful 
enthusiasts,  who  bore  their  lighted  torches  safely  back  across  the  waters. 

Out  of  these  early  essays  in  medical  teaching,  the  American  medical  school  devel- 
oped. As  far  back  as  1750  informal  classes  and  demonstrations,  mainly  in  anatomy, 
are  matters  of  record.  Philadelphia  was  then  the  chief  center  of  medical  interest. 
There,  in  1762,  William  Shippen  the  younger,  after  a  sojourn  of  five  years  abroad, 
began  in  the  very  year  of  his  return  home,  a  course  of  lectures  on  midwifery.  In  the 
following  autumn  he  announced  a  series  of  anatomical  lectures  "  for  the  advantage 
of  the  young  gentlemen  now  engaged  in  the  study  of  physic  in  this  and  the  neighbor- 
ing provinces,  whose  circumstances  and  connections  will  not  admit  of  their  going 
abroad  for  improvement  to  the  anatomical  schools  in  Europe;  and  also  for  the  en- 
tertainment of  any  gentlemen  who  may  have  the  curiosity  to  understand  the  anatomy 
of  the  Human  Frame."  From  these  detached  courses  the  step  to  an  organized  medi- 
cal school  was  taken  at  the  instigation  of  Shippen's  friend  and  fellow  student  abroad, 

1  This  statement  has  reference  only  to  the  United  States  and  Canada,  with  which  the  present  account 
alone  deals.  As  a  matter  of  fact,  a  chair  of  medicine  was  established  at  the  University  of  Mexico 
towards  the  close  of  the  sixteenth  century.  A  complete  medical  school  was  there  developed.  James  J. 
Walsh  :  "First  American  Medical  School,"  in  New  York  Medical  Journal,  Oct.  10,  1908 (based  on 
Historia  de  la  medicina  en  Mexico  des  de  la  epoca  de  los  Iiulios,  hasta  la  present*.  Por  Francisco 
Flores.  Mexico,  1886). 


4  MEDICAL  EDUCATION 

John  Morgan,  who  in  1765  proposed  to  the  trustees  of  the  College  of  Philadelphia 
the  creation  of  a  professorship  in  the  theory  and  practice  of  medicine.  At  the  ensuing 
Commencement,  Morgan  delivered  a  noble  and  prophetic  discourse,  still  pertinent, 
upon  the  institution  of  medical  schools  in  America.  The  trustees  were  favorable  to 
the  suggestion ;  the  chair  was  established,  and  Morgan  himself  was  its  first  occupant. 
Soon  afterwards  Shippen  became  professor  of  anatomy  and  surgery.  Thirteen  years 
previously  the  Pennsylvania  Hospital,  conceived  by  Thomas  Bond,  had  been  estab- 
lished through  the  joint  efforts  of  Bond  himself  and  Benjamin  Franklin.  Realizing 
that  the  student  "must  Join  Examples  with  Study,  before  he  can  be  sufficiently 
qualified  to  prescribe  for  the  sick,  for  Language  and  Books  alone  can  never  give  him 
Adequate  Ideas  of  Diseases  and  the  best  methods  of  Treating  them,"  Bond  now 
argued  successfully  in  behalf  of  bedside  training  for  the  medical  students.  "  There 
the  Clinical  professor  comes  in  to  the  Aid  of  Speculation  and  demonstrates  the  Truth 
of  Theory  by  Facts,"  he  declared  in  words  that  a  century  and  a  half  later  still  warrant 
repetition;  "he  meets  his  pupils  at  stated  times  in  the  Hospital,  and  when  a  case 
presents  adapted  to  his  purpose,  he  asks  all  those  Questions  which  lead  to  a  certain 
knowledge  of  the  Disease  and  parts  Affected;  and  if  the  Disease  baffles  the  power  of 
Art  and  the  Patient  falls  a  Sacrifice  to  it,  he  then  brings  his  Knowledge  to  the  Test, 
and  fixes  Honour  or  discredit  on  his  Reputation  by  exposing  all  the  Morbid  parts 
to  View,  and  Demonstrates  by  what  means  it  produced  Death,  and  if  perchance  he 
finds  something  unexpected,  which  Betrays  an  Error  in  Judgement,  he  like  a  great 
and  good  man  immediately  acknowledges  the  mistake,  and,  for  the  benefit  of  sur- 
vivors, points  out  other  methods  by  which  it  might  have  been  more  happily  treated.""1 
The  writer  of  these  sensible  words  fitly  became  our  first  professor  of  clinical  medi- 
cine,1 with  unobstructed  access  to  the  one  hundred  and  thirty  patients  then  in  the 
hospital  wards.  Subsequently  the  faculty  of  the  new  school  was  increased  and  greatly 
strengthened  when  Adam  Kuhn,  trained  by  Linnaeus,  was  made  professor  of  materia 
medica,  and  Benjamin  Rush,  already  at  twenty-four  on  the  threshold  of  his  brilliant 
career,  became  professor  of  chemistry. 

Our  first  medical  school  was  thus  soundly  conceived  as  organically  part  of  an  in- 
stitution of  learning  and  intimately  connected  with  a  large  public  hospital.  The 
instruction  aimed,  as  already  pointed  out,  not  to  supplant,  but  to  supplement  ap- 
prenticeship. A  year's  additional  training,  carrying  the  bachelor's  degree,  was  offered 
to  students  who,  having  demonstrated  a  competent  knowledge  of  Latin,  mathema- 
tics, natural  and  experimental  philosophy,  and  having  served  a  sufficient  apprentice- 
ship to  some  reputable  practitioner  in  physic,  now  completed  a  prescribed  lecture 
curriculum,  with  attendance  upon  the  practice  of  the  Pennsylvania  Hospital  for  one 

1  An  essay  on  Th»  Utility  of  Clinical  Lecturgt,  by  Thomas  Bond,  1766. 

2 There  is  no  record  of  Dr.  Bond's  appointment,  but  in  the  minutes  of  the  Hospital  trustees  he  "is 
rcouested  by  the  Trustees  and  Professors  to  continue  his  Clinical  Lectures  at  the  Hospital  as  a  Branch 
of  Medical  Education."  Quoted  by  Packard:  Hittory  of  Medicine  in  tht  United  State*,  p.  201. 


HISTORICAL  AND  GENERAL  5 

year.  This  course  was  well  calculated  to  round  off  the  young  doctor's  preparation, 
reviewing  and  systematizing  his  theoretical  acquisitions,  while  considerably  extend- 
ing his  practical  experience. 

Before  the  outbreak  of  the  Revolution,  the  young  medical  school  was  prosperously 
started  on  its  career.  The  war  of  course  brought  interruption  and  confusion.  More 
unfortunate  still,  for  the  time  being,  was  the  local  rivalry — ominous  as  the  first  of 
its  kind — of  the  newly  established  medical  department  of  the  University  of  Penn- 
sylvania; but  wise  counsels  averted  disaster,  and  in  1791  the  two  institutions  joined 
to  form  a  single  faculty,  bearing,  as  it  still  bears,  the  name  of  the  university, — the 
earliest  of  a  long  and  yet  incomplete  series  of  medical  school  mergers.  Before  the 
close  of  the  century  three  more  "  medical  institutes,"  similar  in  style,  had  been  started : 
one  in  1768  in  New  York,  as  the  medical  department  of  King's  College,  which,  how- 
ever, temporarily  collapsed  on  the  British  occupation  and  was  only  indirectly  restored 
to  vigor  by  union  in  1814  with  the  College  of  Physicians  and  Surgeons,  begun  by 
the  Regents  in  1807;  another,  the  medical  department  of  Harvard  College,  opened 
in  Cambridge  in  1783,  and  twenty-seven  years  later  removed  to  Boston  so  as  to 
gain  access  to  the  hospitals  there;1  last  of  the  group,  the  medical  department  of 
Dartmouth  College,  started  in  1798  by  a  Harvard  graduate,  Dr.  Nathan  Smith,  who 
was  himself  for  twelve  years  practically  its  entire  faculty — and  a  very  able  faculty  at 
that. 

The  sound  start  of  these  early  schools  was  not  long  maintained.  Their  scholarly 
ideals  were  soon  compromised  and  then  forgotten.  True  enough,  from  time  to  time 
seats  of  learning  continued  to  create  medical  departments, — Yale  in  1810,  Transyl- 
vania in  1817,  among  others.  But  with  the  foundation  early  in  the  nineteenth  cen- 
tury at  Baltimore  of  a  proprietary  school,  the  so-called  medical  department  of  the 
so-called  University  of  Maryland,2  a  harmful  precedent  was  established.3  Before  that 
a  college  of  medicine  had  been  a  branch  growing  out  of  the  living  university  trunk. 

1  The  removal  took  place  in  1810.  But  definite  arrangements  for  clinical  teaching  long  remained  vague. 
Dr.  R.  C.  Cabot  quotes.the  Harvard  Catalogue  of  1833  as  follows :  "  The  lectures  for  medical  students 
are  delivered  in  Boston.  .  .  .  During  lectures  the  students  may  find  in  the  city  various  opportunities 
for  practical  instruction."  A  hospital  is  first  mentioned  in  1835,  "  when  it  is  stated  that  students  may 
attend  the  medical  visits  at  the  Massachusetts  General  Hospital."  R.  C.  Cabot:  "Sketch  of  the  De- 
velopment of  the  Department  of  Clinical  Medicine,"  in  Harvard  Medical  Alumni  Quarterly,  Jan.,  1904, 
p.  666. 

2  In  recent  years  an  effort  has  been  made  to  fill  out  the  non-existent  university  by  an  affiliation  with 
St.  John's  College  (Annapolis),  whereby  it  becomes  nominally  the  department  of  arts  of  the  Univer- 
sity of  Maryland.  This  is,  of  course,  a  makeshift.  A  university  begins  with  a  school  of  arts  and 
sciences ;  it  cannot  be  formed  of  loosely  associated  schools  of  dentistry,  pharmacy,  and  even  law, 
whether  with  or  without  still  looser  connection  with  a  remote  college  of  arts.  Analogous  in  type  are 
the  so-called  medical  departments  of  the  Universities  of  Buffalo,  Toledo,  and  Memphis,  which  at  this 
writing  still  lack  academic  affiliation.  Their  titles  cannot  disguise  the  fact  that  they  are  in  essence  in- 
dependent medical  schools,  nor  does  a  university  charter  make  a  university. 

3  This  was  in  imitation  of  London,  as  against  the  Edinburgh  or  the  Leyden  example,  followed  by  the 
four  earlier  schools.  But  the  London  schools  never  conferred  the  degree  or  gave  the  right  to  practise  : 
for  the  bestowal  of  degrees  is  the  function  of  a  university,  the  qualification  for  practice  is  determined 
by  the  state.  The  American  departure  in  both  these  respects  developed  evils  from  which  England  has 
never  suffered. 


6  MEDICAL  EDUCATION 

This  organic  connection  guaranteed  certain  standards  and  ideals,  modest  enough  at 
that  time,  but  destined  to  a  development  which  medical  education  could,  as  experi- 
ence proved,  ill  afford  to  forego.  Even  had  the  university  relation  been  preserved, 
the  precise  requirements  of  the  Philadelphia  College  would  not  indeed  have  been 
permanently  tenable.  The  rapid  expansion  of  the  country,  with  the  inevitable  decay 
of  the  apprentice  system  in  consequence,  must  necessarily  have  lowered  the  terms  of 
entrance  upon  the  study.  But  for  a  time  only :  the  requirements  of  medical  educa- 
tion would  then  have  slowly  risen  with  the  general  increase  in  our  educational  re- 
sources. Medical  education  would  have  been  part  of  the  entire  movement  instead  of 
an  exception  to  it.  The  number  of  schools  would  have  been  well  within  the  number 
of  actual  universities,  in  whose  development  as  respects  endowments,  laboratories, 
and  libraries  they  would  have  partaken;  and  the  country  would  have  been  spared 
the  demoralizing  experience  in  medical  education  from  which  it  is  but  now  painfully 
awakening. 

Quite  aside  from  the  history,  achievements,  or  present  merits  of  any  particular  in- 
dependent medical  school,  the  creation  of  the  type  was  the  fertile  source  of  unfore- 
seen harm  to  medical  education  and  to  medical  practice.  Since  that  day  medical  col- 
leges have  multiplied  without  restraint,  now  by  fission,  now  by  sheer  spontaneous 
generation.  Between  1810  and  1840,  twenty-six  new  medical  schools  sprang  up;  be- 
tween 1840  and  1876,  forty-seven  more;1  and  the  number  actually  surviving  in  1876 
has  been  since  then  much  more  than  doubled.  First  and  last,  the  United  States  and 
Canada  have  in  little  more  than  a  century  produced  four  hundred  and  fifty-seven 
medical  schools,  many,  of  course,  short-lived,  and  perhaps  fifty  still-born.2  One 
hundred  and  fifty-five  survive  to-day.5  Of  these,  Illinois,  prolific  mother  of  thirty- 
nine  medical  colleges,  still  harbors  in  the  city  of  Chicago  fourteen ;  forty-two  sprang 
from  the  fertile  soil  of  Missouri,  twelve  of  them  still  "going"  concerns;  the  Empire 
State  produced  forty -three,  with  eleven  survivors;4  Indiana,  twenty-seven,  with  two 
survivors;  Pennsylvania,  twenty,  with  eight  survivors;  Tennessee,  eighteen,  with 
nine  survivors.  The  city  of  Cincinnati  brought  forth  about  twenty,  the  city  of 
Louisville  eleven.  These  enterprises — for  the  most  part  they  can  be  called  schools 
or  institutions  only  by  courtesy — were  frequently  set  up  regardless  of  opportunity 
or  need:  in  small  towns  as  readily  as  in  large,  and  at  times  almost  in  the  heart  of  the 
wilderness.  No  field,  however  limited,  was  ever  effectually  preempted.  Wherever  and 
whenever  the  roster  of  untitled  practitioners  rose  above  half  a  dozen,  a  medical 
school  was  likely  at  any  moment  to  be  precipitated.  Nothing  was  really  essential  but 

lContrib.  to  Hittory  ofMed.  Educat.,  N.  S.  Davis  (Washington,  1877,  p.  41). 

•These  were  usually  frauds,  suppressed  by  police  or  by  post-office  departments.  Postgraduate  and 
osteopathic  schools  are  not  included  in  these  figures. 

1  Including  osteopathic  schools,  of  which  there  are  eight,  but  not  including  postgraduate  schools,  of 
which  there  are  thirteen,  one  of  them  in  Kansas  City  without  students  at  present.  The  last-named 
institution  retains  its  organization  in  order  to  obtain  staff  recognition  at  the  Kansas  City  Hospital. 

*  Not  including  four  postgraduate  schools. 


HISTORICAL  AND  GENERAL  7 

professors.  The  laboratory  movement  is  comparatively  recent;  and  Thomas  Bond's 
wise  words  about  clinical  teaching  were  long  since  out  of  print.  Little  or  no  invest- 
ment was  therefore  involved.  A  hall  could  be  cheaply  rented  and  rude  benches  were 
inexpensive.  Janitor  service  was  unknown  and  is  even  now  relatively  rare.  Occasional 
dissections  in  time  supplied  a  skeleton — in  whole  or  in  part — and  a  box  of  odd 
bones.  Other  equipment  there  was  practically  none.  The  teaching  was,  except  for  a 
little  anatomy,  wholly  didactic.  The  schools  were  essentially  private  ventures,  money- 
making  in  spirit  and  object.  A  school  that  began  in  October  would  graduate  a  class  the 
next  spring;  it  mattered  not  that  the  course  of  study  was  two  or  three  years ;  immigra- 
tion recruited  a  senior  class  at  the  start.1  Income  was  simply  divided  among  the  lec- 
turers, who  reaped  a  rich  harvest,  besides,  through  the  consultations  which  the  loyalty 
of  their  former  students  threw  into  their  hands. "  Chairs  "  were  therefore  valuable  pieces 
of  property,  their  prices  varying  with  what  was  termed  their  "reflex"  value:  only  re- 
cently a  professor  in  a  now  defunct  Louisville  school,  who  had  agreed  to  pay  $3000 
for  the  combined  chair  of  physiology  and  gynecology,  objected  strenuously  to  a  di- 
vision of  the  professorship  assigning  him  physiology,  on  the  ground  of  "failure  of 
consideration;"  for  the  "reflex"  which  constituted  the  inducement  to  purchase  went 
obviously  with  the  other  subject.2  No  applicant  for  instruction  who  could  pay  his 
fees  or  sign  his  note  was  turned  down/ State  boards  were  not  as  yet  in  existence.  The 
school  diploma  was  itself  a  license  to  practise.  The  examinations,  brief,  oral,  and  se- 
cret, plucked  almost  none  at  all;  even  at  Harvard,  a  student  for  whom  a  majority 
of  nine  professors  "voted"  was  passed.3  The  man  who  had  settled  his  tuition  bill  was 
thus  practically  assured  of  his  degree,  whether  he  had  regularly  attended  lectures  or 
not.  Accordingly,  the  business  throve.  Rivalry  between  different  so-called  medical 
centers  was  ludicrously  bitter.  Still  more  acrid  were — and  occasionally  are — the  local 
animosities  bound  to  arise  in  dividing  or  endeavoring  to  monopolize  the  spoils.  Sud- 
den and  violent  feuds  thus  frequently  disrupted  the  faculties.  But  a  split  was  rarely 
fatal:  it  was  more  likely  to  result  in  one  more  school.  Occasionally,  a  single  too 
masterful  individual  became  the  strategic  object  of  a  hostile  faculty  combination. 
Daniel  Drake,  indomitable  pioneer  in  medical  education  up  and  down  the  Ohio  Val- 
ley, thus  tasted  the  ingratitude  of  his  colleagues.  As  presiding  officer  of  the  faculty 
of  the  Medical  College  of  Ohio,  at  Cincinnati,  cornered  by  a  cabal  of  men,  only  a 
year  since  indebted  to  him  for  their  professorial  titles  and  profits,  he  was  compelled 
to  put  a  motion  for  his  own  expulsion  and  to  announce  to  his  enemies  a  large  major- 

1  This  is  recent  as  well  as  ancient  history,  e.g. : 

Tufts  College  Medical  School                                   opened  1893  first  class  graduated  1894 

Illinois  Medical  College                                                            18»4  1885 

Birmingham  Medical  College                                                1894  1895 

College  of  Physjcians  and  Surgeons,  Little  Rock               1906  1907 

College  of  Physicians  and  Surgeons,  Memphis                   1900  1907 

2  The  sale  of  chairs  is  not  even  now  wholly  unknown.  At  the  North  Carolina  Medical  College  (Char- 
lotte, N.  C.)  the  faculty  owns  the  stock,  and  the  sale  of  one's  stock  carries  with  it  one's  chair. 

3  There  were  at  Harvard  at  one  time  only  seven  professors  and  an  examination  was  conducted  even 
if  only  a  majority  was  present. 


8  MEDICAL  EDUCATION 

ity  in  its  favor.  It  is  pleasant  to  record  that  the  indefatigable  man  was  not  daunted. 
He  continued  from  time  to  time  to  found  schools  and  to  fill  professorships — at  Lex- 
ington, at  Philadelphia,  at  Oxford  in  Ohio,  at  Louisville,  and  finally  again  in  that 
beloved  Cincinnati,  where  he  had  been  so  hardly  served.  In  the  course  of  a  busy 
and  fruitful  career,  he  had  occupied  eleven  different  chairs  in  six  different  schools, 
several  of  which  he  had  himself  founded ;  and  he  had  besides  traversed  the  whole 
country,  as  it  then  was,  from  Canada  and  the  Great  Lakes  to  the  Gulf,  and  as  far 
westward  as  Iowa,  collecting  material  for  his  great  work,  historically  a  classic,  The 
Diseases  of  the  Interior  Valley  of  North  America. 

In  the  wave  of  commercial  exploitation  which  swept  the  entire  profession  so  far 
as  medical  education  is  concerned,  the  original  university  departments  were  practi- 
cally torn  from  their  moorings.  The  medical  schools  of  Harvard,  Yale,  Pennsylvania, 
became,  as  they  expanded,  virtually  independent  of  the  institutions  with  which  they 
were  legally  united,  and  have  had  in  our  own  day  to  be  painfully  won  back  to  their 
former  status.1  For  years  they  managed  their  own  affairs,  disposing  of  professor- 
ships by  common  agreement,  segregating  and  dividing  fees,  along  proprietary  lines. 
In  general,  these  indiscriminate  and  irresponsible  conditions  continued  at  their 
worst  until  well  into  the  eighties.  To  this  day  it  is  as  easy  to  establish  a  medical 
school  as  a  business  college,1  though  the  inducement  and  tendency  to  do  so  have 
greatly  weakened.  Meanwhile,  the  entire  situation  had  fundamentally  altered.  The 
preceptorial  system,  soon  moribund,  had  become  nominal.  The  student  registered  in 
the  office  of  a  physician  whom  he  never  saw  again.  He  no  longer  read  his  master's 
books,  submitted  to  his  quizzing,  or  rode  with  him  the  countryside  in  the  enjoy- 
ment of  valuable  bedside  opportunities.  All  the  training  that  a  young  doctor  got 
before  beginning  his  practice  had  now  to  be  procured  within  the  medical  school.  The 
school  was  no  longer  a  supplement;  it  was  everything.  Meanwhile,  the  practice  of 
medicine  was  itself  becoming  quite  another  thing.  Progress  in  chemical,  biological, 
and  physical  science  was  increasing  the  physician's  resources,  both  diagnostic  and 
remedial.  Medicine,  hitherto  empirical,  was  beginning  to  develop  a  scientific  basis 
and  method.  The  medical  schools  had  thus  a  different  function  to  perform :  it  took 
them  upwards  of  half  a  century  to  wake  up  to  the  fact.  The  stethoscope  had  been 
in  use  for  over  thirty  years  before,  as  Dr.  Cabot  notes,3  its  first  mention  in  the  cata- 
logue of  the  Harvard  Medical  School  in  1868-9;  the  microscope  is  first  mentioned 

1The  first  step  towards  depriving  the  medical  school  of  virtual  autonomy  was  taken  when  the  univer- 
sity undertook  to  collect  the  fees  and  thenceforward  to  administer  the  finances  of  the  department  by 
means  of  an  annual  budget.  This  took  place  at  Harvard  in  1871,  at  Yale  in  1880,  at  the  University 
of  Pennsylvania  in  1896.  The  scope  of  the  medical  faculty  has  gradually  shrunk  since.  Columbia, 
which  gave  up  its  medical  department  to  the  College  of  Physicians  and  Surgeons  in  1814,  contracted 
a  nominal  relation  with  that  school  in  I860;  in  1891  the  connection  became  organic. 

*  In  New  York,  however,  the  chartering  of  educational  institutions  is  in  the  hands  of  the  Regents, 
who  have  large  powers.  Nevertheless,  they  have  recently  given  a  limited  charter  to  the  Brooklyn 
Postgraduate  School,  a  corporation  practically  without  resources  and  relying  on  hospital  and  student 
fee  income  (the  latter  thus  far  small)  to  carry  it  through. 
•Cabot,  loc.  cit.,  p.  673. 


HISTORICAL  AND  GENERAL  9 

the  following  year.  The  schools  had  not  noticed  at  all  when  the  vital  features  of 
the  apprentice  system  dropped  out.  They  continued  along  the  old  channel,  their 
ancient  methods  aggravated  by  rapid  growth  in  the  number  of  students  and  by  the 
lowering  in  the  general  level  of  their  education  and  intelligence.  Didactic  lectures 
were  given  in  huge,  badly  lighted  amphitheaters,  and  in  these  discourses  the  instruc- 
tion almost  wholly  consisted.  Personal  contact  between  teacher  and  student,  be- 
tween student  and  patient,  was  lost.  No  consistent  effort  was  made  to  adapt  medical 
training  to  changed  circumstances.  Many  of  the  schools  had  no  clinical  facilities 
whatsoever,  and  the  absence  of  adequate  clinical  facilities  is  to  this  day  not  prohibi- 
tive. The  school  session  had  indeed  been  lengthened  to  two  sessions;  but  they  were 
of  only  sixteen  to  twenty  weeks  each.  Moreover,  the  course  was  not  graded  and  the 
two  classes  were  not  separated.  The  student  had  two  chances  to  hear  one  set  of  lec- 
tures— and  for  the  privilege  paid  two  sets  of  fees.  To  this  traffic  many  of  the  ablest 
practitioners  in  the  country  were  parties,  and  with  little  or  no  realization  of  its 
enormity  at  that!  "It  is  safe  to  say,"  said  Henry  J.  Bigelow,  professor  of  surgery 
at  Harvard  in  1871,  "that  no  successful  school  has  thought  proper  to  risk  large 
existing  classes  and  large  receipts  in  attempting  a  more  thorough  education."1  A 
minority  successfully  wrung  a  measure  of  good  from  the  vicious  system  which  they 
were  powerless  to  destroy.  They  contrived  to  reach  and  to  inspire  the  most  capable 
of  their  hearers.  The  best  products  of  the  system  are  thus  hard  to  reconcile  with  the 
system  itself.  Competent  and  humane  physicians  the  country  came  to  have, — at 
whose  and  at  what  cost,  one  shudders  to  reflect;  for  the  early  patients  of  the  rapidly 
made  doctors  must  have  played  an  unduly  large  part  in  their  practical  training.  An 
annual  and  increasing  exodus  to  Europe  also  did  much  to  repair  the  deficiencies  of 
students  who  would  not  have  neglected  better  opportunities  at  home.  The  Edin- 
burgh and  London  tradition,  maintained  by  John  Bell,  Abernethy,  and  Sir  Astley 
Cooper,  persisted  well  into  the  century.  In  the  thirties,  Paris  became  the  medical 
student's  Mecca,  and  the  statistical  and  analytical  study  of  disease,  which  is  the  dis- 
criminating mark  of  modern  scientific  medicine,  was  thence  introduced  into  America 
by  the  pupils  of  Louis,2 — the  younger  Jackson,  "dead  ere  his  prime,"  Gerhard,  and 
their  successors.  With  the  generation  succeeding  the  civil  war,  the  tide  turned  decisively 
towards  Germany,  and  thither  continues  to  set.  These  men  subsequently  became 
teachers  in  the  colleges  at  Philadelphia,  New  York,  Boston,  Charleston,  and  else- 
where; and  from  them  the  really  capable  and  energetic  students  got  much.  One 
of  the  latter,  who  in  recent  years  has  wielded  perhaps  the  greatest  single  influence  in 
the  country  towards  the  reconstruction  of  medical  education,  says  of  his  own  school, 
the  College  of  Physicians  and  Surgeons  of  New  York,  in  the  early  seventies:  "One 
can  decry  the  system  of  those  days,  the  inadequate  preliminary  requirements,  the 
short  courses,  the  dominance  of  the  didactic  lecture,  the  meager  appliances  for 

1  Medical  Education  in  America,  by  Henry  J.  Bigelow,  Cambridge,  the  University  Press,  1871,  p.  79. 
a  Osier :  • '  Influence  of  Louis  on  Modern  Medicine, "  Bulletin  Johns  Hopkins  Hospital,  vol.  iii. ,  nos.  77, 78. 


10  MEDICAL  EDUCATION 

demonstrative  and  practical  instruction,  but  the  results  were  better  than  the  system. 
Our  teachers  were  men  of  fine  character,  devoted  to  the  duties  of  their  chairs;  they 
inspired  us  with  enthusiasm,  interest  in  our  studies  and  hard  work,  and  they  imparted 
to  us  sound  traditions  of  our  profession ;  nor  did  they  send  us  forth  so  utterly  igno- 
rant and  unfitted  for  professional  work  as  those  born  of  the  present  greatly  improved 
methods  of  training  and  opportunities  for  practical  studies  are  sometimes  wont  to 
suppose.  Clinical  and  demonstrative  teaching  for  undergraduates  already  existed.  Of 
laboratory  training  there  was  none.1" l  As  much  could  perhaps  be  said  of  a  half-dozen 
other  institutions.  The  century  was  therefore  never  without  brilliant  names  in  ana- 
tomy, medicine,  and  surgery;  but  they  can  hardly  be  cited  in  extenuation  of  condi- 
tions over  which  unusual  gifts  and  perseverance  alone  could  triumph.  Those  con- 
ditions made  uniform  and  thorough  teaching  impossible;  and  they  utterly  forbade 
the  conscientious  elimination  of  the  incompetent  and  the  unfit. 

From  time  to  time,  of  course,  the  voice  of  protest  was  heard,  but  it  was  for  years 
a  voice  crying  in  the  wilderness.  Delegates  from  medical  schools  and  societies  met  at 
Northampton,  Massachusetts,  in  1827,  and  agreed  upon  certain  recommendations 
lengthening  the  term  of  medical  study  and  establishing  a  knowledge  of  Latin  and 
natural  philosophy  as  preliminary  thereto.  The  Yale  Medical  School  actually  went 
so  far  as  to  procure  legislation  to  this  end.  But  it  subsequently  beat  a  retreat  when 
it  found  itself  isolated  in  its  advanced  position,  its  quondam  allies  having  failed  to 
march.2  As  far  back  as  1835,  the  Medical  College  of  Georgia  had  vainly  suggested 
concerted  action  looking  to  more  decent  methods;  but  no  step  was  taken  until,  eleven 
years  later,  an  agitation  set  up  by  Nathan  Smith  Davis  resulted  in  the  formation  of 
the  American  Medical  Association,  committed  to  two  propositions,  viz.)  that  it  is 
desirable  "that  young  men  received  as  students  of  medicine  should  have  acquired  a 
suitable  preliminary  education,"  and  "that  a  uniform  elevated  standard  of  require- 
ments for  the  degree  of  M.D.  should  be  adopted  by  all  the  medical  schools  in  the 
United  States."  This  was  in  1846;  much  water  has  flowed  under  the  bridge  since 
then;  and  though  neither  of  these  propositions  has  even  yet  been  realized,  there  is  no 
denying  that,  especially  in  the  last  fifteen  years,  substantial  progress  has  been  made. 

In  the  first  place,  the  course  has  now  at  length  been  generally  graded  *  and  ex- 

1Wm.  H.  Welch:  "Development  of  American  Medicine,"  Columbia  Unwerrity  Quarterly  Supple- 
ment, Dec.,  1907. 

1  Wm.  H.  Welch : "  The  Relation  of  Yale  to  Medicine  "  (reprinted  from  Yale  Medical  Journal  for  Nov., 
1901),  p.  20,  and  note  28,  pp.  30,  31. 

•A  certain  amount  of  ungraded  teaching  is  still  to  be  found,  especially  in  the  south  and  west.  For 
example,  at  Chattanooga,  no  examinations  are  held  at  the  close  of  the  first  year ;  the  examinations  at 
the  close  of  the  second  year  are  supposed  to  cover  two  years'  work,  the  practical  outcome  of  which 
is  obvious.  More  frequently,  clinical  lectures  are  delivered  to  the  juniors  and  seniors  together, — at 
least,  as  far  as  a  single  amphitheater  is  capable  of  containing  the  combined  classes.  This  is  the  case 
at  the  University  of  Louisville.  At  certain  other  schools,  the  work  is  only  partially  graded,  e.g.,  the 
Memphis  Hospital  Medical  College,  Tennessee  Medical  College,  University  of  Arkansas,  Birmingham 
Medical  College,  Ensworth  Medical  College  (St.  Joseph.  Mo.),  Hahnemann,  San  Francisco,  Kansas 
Medical  (Topeka),  Woman's  Medical  (Baltimore),  Maryland  Medical,  Mississippi  Medical,  American 


HISTORICAL  AND  GENERAL  11 

tended  to  four  years,  still  varying,  however,  from  six  l  to  nine  months  each  in  du- 
ration. Didactic  teaching  has  been  much  mitigated.  Almost  without  exception  the 
schools  furnish  some  clinical  teaching;  many  of  them  provide  a  fair  amount,  though 
it  is  still  only  rarely  used  to  the  best  teaching  advantage;  a  few  are  quite  adequately 
equipped  in  this  respect.  Relatively  quicker  and  greater  progress  has  been  made  on 
the  laboratory  side  since,  in  1878,2  Dr.  Francis  Delafield  established  the  laboratory 
of  the  Alumni  Association  of  the  College  of  Physicians  and  Surgeons  of  New  York ; 3 
in  the  same  autumn  Dr.  William  H.  Welch  opened  the  pathological  laboratory  of 
the  Bellevue  Hospital  Medical  College,  from  which,  six  years  later,  he  was  called  to 
organize  the  Johns  Hopkins  Medical  School  in  Baltimore.  It  is  at  length  everywhere 
conceded  that  the  prospective  student  of  medicine  should  prove  his  fitness  for  the 
undertaking.  Not  a  few  schools  rest  on  a  substantial  admission  basis ;  the  others  have 
not  yet  abandoned  the  impossible  endeavor  at  one  and  the  same  time  to  pay  their  own 
way  and  to  live  up  to  standards  whose  reasonableness  they  cannot  deny.  Finally,  the 
creation  of  state  boards  has  compelled  a  greater  degree  of  conscientiousness  in  teach- 
ing, though  in  many  places,  unfortunately,  far  too  largely  the  conscientiousness  of 
the  drillmaster. 

In  consequence  of  the  various  changes  thus  briefly  recounted,  the  number  of  med- 
ical schools  has  latterly  declined.  Within  a  twelvemonth  a  dozen  have  closed  their 
doors.  Many  more  are  obviously  gasping  for  breath.  Practically  without  exception, 
the  independent  schools  are  scanning  the  horizon  in  search  of  an  unoccupied  univer- 
sity harbor.  It  has,  in  fact,  become  virtually  impossible  for  a  medical  school  to  com- 
ply even  in  a  perfunctory  manner  with  statutory,  not  to  say  scientific,  requirements 
and  show  a  profit.  The  medical  school  that  distributes  a  dividend  to  its  professors 
or  pays  for  buildings  out  of  fees  must  cut  far  below  the  standards  which  its  own 
catalogue  probably  alleges.  Nothing  has  perhaps  done  more  to  complete  the  dis- 
credit of  commercialism  than  the  fact  that  it  has  ceased  to  pay.  It  is  but  a  short 
step  from  an  annual  deficit  to  the  conclusion  that  the  whole  thing  is  wrong  anyway. 

In  the  first  place,  however,  the  motive  power  towards  better  conditions  came  from 
genuine  professional  and  scientific  conviction.  The  credit  for  the  actual  initiative 
belongs  fairly  to  the  institutions  that  had  the  courage  and  the  virtue  to  make 
the  start.  The  first  of  these  was  the  Chicago  school,  which  is  now  the  medical  de- 
Medical  (St.  Louis),  St.  Louis  College  of  Physicians  and  Surgeons,  Barnes  Medical,  Western  Eclec- 
tic (Kansas  City),  Eclectic  Medical  (New  York),  Eclectic  Institute  (Cincinnati). 
1The  low-grade  southern  schools  have  a  nominal  seven  months'  course;  but  as  they  allow  students 
to  enter  without  penalty  several  weeks  later  and  have  liberal  Christmas  holidays  besides,  the  course 
is  actually  less  than  six  months. 

2  Prior  to  this  date  Drs.  Francis  Delafield,  E.  G.  Janeway,  and  others  had  given  courses  at  Bellevue 
Hospital  and  elsewhere  in  histology,  pathology,  etc.  See  George  C.  Freeborn  :  History  of  the  Associa- 
tion of  the  Alumni  of  the  College  of  Physicians  and  Surgeons,  New  York,  p.  10,  etc.  Instruction  in 
pathological  anatomy  in  the  Harvard  Medical  School  had  begun  in  1870  with  the  appointment  of 
Dr.  R.  H.  Fitz  to  an  instructorship  in  that  subject. 

5  This  laboratory  was  at  first  independent  of  the  faculty  of  the  College  of  Physicians  and  Surgeons. 


12  MEDICAL  EDUCATION 

partment  of  Northwestern  University,  and  which  in  1859  initiated  a  three-year 
graded  course.  Early  in  the  seventies  the  new  president  of  Harvard  College  startled 
the  bewildered  faculty  of  its  medical  school  into  the  first  of  a  series  of  reforms  that 
began  with  the  grading  of  the  existing  course  and  ended  in  1901  with  the  require- 
ment of  an  academic  degree  for  admission.1  In  the  process,  the  university  obtained 
the  same  sort  of  control  over  its  medical  department  that  it  exercises  elsewhere.2 
Towards  this  consummation  President  Eliot  had  aimed  from  the  start;  but  he  was 
destined  to  be  anticipated  by  the  establishment  in  1893  of  the  Johns  Hopkins  Med- 
ical School  on  the  basis  of  a  bachelors  degree,  from  which,  with  quite  unprecedented 
academic  virtue,  no  single  exception  has  ever  been  made.8  This  was  the  first  medical 
school  in  America  of  genuine  university  type,  with  something  approaching  adequate 
endowment,  well  equipped  laboratories  conducted  by  modern  teachers,  devoting  them- 
selves unreservedly  to  medical  investigation  and  instruction, and  with  its  own  hospital, 
in  which  the  training  of  physicians  and  the  healing  of  the  sick  harmoniously  combine 
to  the  infinite  advantage  of  both.  The  influence  of  this  new  foundation  can  hardly 
be  overstated.  It  has  finally  cleared  up  the  problem  of  standards  and  ideals;  and  its 
graduates  have  gone  forth  in  small  bands  to  found  new  establishments  or  to  recon- 
struct old  ones.  In  the  sixteen  years  that  have  since  elapsed,  fourteen  more  institu- 
tions have  actually  advanced  to  the  basis  of  two  or  more  years  of  college  work ;  others 
have  undertaken  shortly  to  do  so.  Besides  these,  there  are  perhaps  a  dozen  other 
more  or  less  efficient  schools  whose  entrance  requirements  hover  hazily  about  high 
school  graduation.  In  point  of  organization,  the  thirty-odd  schools  now  supplying 
the  distinctly  better  quality  of  medical  training  are  not  as  yet  all  of  university  type. 
Thither  they  are  unquestionably  tending;  for  the  moment,  however,  the  very  best 
and  some  of  the  very  worst*  are  alike  known  as  university  departments.  Not  a  few 
so-called  university  medical  departments  are  such  in  name  only.  They  are  practically 
independent  enterprises,  to  which  some  university  has  good-naturedly  lent  its  pres- 
tige. The  College  of  Physicians  and  Surgeons  of  Chicago  is  the  medical  department 
of  the  University  of  Illinois,  but  the  relation  between  them  is  purely  contractual ; 
the  state  university  contributes  nothing  to  its  support  The  Southwestern  University 
of  Texas  possesses  a  medical  department  at  Dallas,  but  the  university  is  legally 
protected  against  all  responsibility  for  its  debts.5  These  fictitious  alignments  retard 

1Seepage28. 

1 A  vein  of  unmistakable  uneasiness  runs  through  Bigelow's  address  on  Medical  Education  in  America, 
previously  referred  to:  "Most  American  medical  colleges  are  virtually  close  corporations,  .  .  .  ad- 
ministered by  their  professors,  who  receive  the  students'  fees,  and  upon  whose  tact  and  ability  the 
success  of  these  institutions  depends.  A  university  possesses  over  all  its  departments  a  legal  jurisdic- 
tion ;  but  it  may  be  a  question  of  expediency  how  far  this  shall  be  enforced"  (p.  59). 

•See,  however,  p.  28. 

*«.a..  University  of  Arkansas,  Willamette  University,  Cotner  University  (Lincoln,  Nebraska),  West- 
ern University  (London,  Ontario),  Epworth  University,  Fort  Worth  University,  etc. 

•Other  university  departments  of  this  nominal  character  are:  medical  department  of  the  University 
of  Arkansas  (Little  Rock);  College  of  Physicians  and  Surgeons  (Los  Angeles),  which  is  nominally 
the  medical  department  of  the  University  of  Southern  California;  Denver  and  Gross  College  of 


HISTORICAL  AND  GENERAL  13 

the  readjustment  of  medical  education  through  further  reduction  in  the  number  of 
schools,  because  the  institutions  involved  are  enabled  to  live  on  hope  for  perhaps 
another  decade  or  more.  It  is  important  that  our  universities  realize  that  medical 
education  is  a  serious  and  costly  venture;  and  that  they  should  reject  or  terminate 
all  connection  with  a  medical  school  unless  prepared  to  foot  its  bills  and  to  pitch  its 
instruction  on  a  university  plane.  In  Canada  conditions  have  never  become  so  badly 
demoralized  as  in  the  United  States.  There  the  best  features  of  English  clinical 
teaching  had  never  been  wholly  forgotten.  Convalescence  from  a  relatively  mild  over- 
indulgence in  commercial  medical  schools  set  in  earlier  and  is  more  nearly  completed. 

With  the  creation  of  the  heterogeneous  situation  thus  bequeathed  to  us,  it  is  clear 
that  consideration  for  the  public  good  has  had  on  the  whole  little  to  do;  nor  is  it  to 
be  expected  that  this  situation  will  very  readily  readjust  itself  in  response  to  public 
need.  A  powerful  and  profitable  vested  interest  tenaciously  resists  criticism  from  that 
point  of  view;  not,  of  course,  openly.  It  is  too  obvious  that  if  the  sick  are  to  reap 
the  full  benefit  of  recent  progress  in  medicine,  a  more  uniformly  arduous  and  expen- 
sive medical  education  is  demanded.  But  it  is  speciously  argued  that  improvements 
thus  accomplished  will  do  more  harm  than  good:  for  whatever  makes  medical  edu- 
cation more  difficult  and  more  costly  will  deplete  the  profession  and  thus  deprive 
large  numbers  of  all  medical  attention  whatsoever,  in  order  that  a  fortunate  minority 
may  get  the  best  possible  care.  It  is  important  to  forestall  the  issue  thus  raised; 
otherwise  it  will  crop  out  at  every  turn  of  the  following  discussion,  in  the  effort  to 
justify  the  existing  situation  and  to  break  the  force  of  constructive  suggestion.  It 
seems,  therefore,  necessary  to  refer  briefly  at  this  point  to  the  statistical  aspects  of 
medical  education  in  America,  so  far  as  they  are  immediately  pertinent  to  the  ques- 
tion of  improvement  and  reform. 

The  problem  is  of  course  practical  and  not  academic.  Pending  the  homogeneous 
filling  up  of  the  whole  country,  inequalities  must  be  tolerated.  Man  has  been  not  in- 
aptly differentiated  as  the  animal  with  "the  desire  to  take  medicine."1  When  sick, 
he  craves  the  comfort  of  the  doctor, — any  doctor  rather  than  none  at  all,  and  in  this 
he  will  not  be  denied.  The  question  is,  then,  not  merely  to  define  the  ideal  training 
of  the  physician;  it  is  just  as  much,  at  this  particular  juncture,  to  strike  the  solution 
that,  economic  and  social  factors  being  what  they  are,  will  distribute  as  widely  as 
possible  the  best  type  of  physician  so  distributable.  Doubtless  the  chaos  above  char- 
acterized is  in  part  accounted  for  by  crude  conditions  that  laughed  at  regular  me- 
thods of  procedure.  But  this  stage  of  our  national  existence  has  gone  by.  What  with 
widely  ramifying  railroad  and  trolley  service,  improving  roads,  automobiles,  and 

Medicine,  which  is  nominally  the  medical  department  of  the  University  of  Denver;  School  of  Medi- 
cine of  the  University  of  Georgia;  Albany  (New  York)  Medical  College,  which  is  nominally  the 
medical  department  of  Union  TJniversity;  medical  department  of  Western  University  (London, 
Ont.),  etc.  For  none  of  these  alliances  is  there  a  valid  reason;  on  the  contrary,  there  is  in  every 
instance  a  good  reason  why  the  university  concerned  should  break  off  the  connection. 

1  Osier:  Aequanimitas,  p.  131. 


14 


MEDICAL  EDUCATION 


rural  telephones,  we  have  measurably  attained  some  of  the  practical  consequences  of 
homogeneity.  The  experience  of  older  countries  is  therefore  suggestive,  even  if  not 
altogether  conclusive. 

Professor  Paulsen,  describing  in  his  book  on  the  German  Universities  the  increased 
importance  of  the  medical  profession,  reports  with  some  astonishment  that  "the 
number  of  physicians  has  increased  with  great  rapidity  so  that  now  there  is,  in  Ger- 
many, one  doctor  for  every  2000  souls,  and  in  the  large  cities  one  for  every  1000."1 
What  would  the  amazed  philosopher  have  said  had  he  known  that  in  the  entire 
United  States  there  is  already  on  the  average  one  doctor  for  every  568  persons,  that 
in  our  large  cities  there  is  frequently  one  doctor  for  every  400 a  or  less,  that  many 
small  towns  with  less  than  200  inhabitants  each  have  two  or  three  physicians  apiece!8 

Over-production  is  stamped  on  the  face  of  these  facts ;  and  if,  in  its  despite,  there 
are  localities  without  a  physician,  it  is  clear  that  even  long-continued  over-produc- 
tion of  cheaply  made  doctors  cannot  force  distribution  beyond  a  well  marked  point. 
In  our  towns  health  is  as  good  and  physicians  probably  as  alert  as  in  Prussia;  there 
is,  then,  no  reason  to  fear  an  unheeded  call  or  a  too  tardy  response,  if  urban  commu- 
nities support  one  doctor  for  every  2000  inhabitants.  On  that  showing,  the  towns 
have  now  four  or  more  doctors  for  every  one  that  they  actually  require, — something 
worse  than  waste,  for  the  superfluous  doctor  is  usually  a  poor  doctor.  So  enormous 
an  overcrowding  with  low-grade  material  both  relatively  and  absolutely  decreases 
the  number  of  well  trained  men  who  can  count  on  the  profession  for  a  livelihood. 
According  to  Gresham's  law,  which,  as  has  been  shrewdly  remarked,  is  as  valid  in  edu- 
cation as  in  finance,  the  inferior  medium  tends  to  displace  the  superior.  If  then,  by 
having  in  cities  one  doctor  for  every  2000  persons,  we  got  four  times  as  good  a  doc- 
tor as  now  when  we  provide  one  doctor  for  every  500  or  less,  the  apothecaries  would 
find  time  hanging  somewhat  more  heavily  on  their  hands.  Clearly,  low  standards 
and  poor  training  are  not  now  needed  in  order  to  supply  physicians  to  the  towns. 

1  Thilly's  translation,  p.  400. 

2  New  York,  1 :  460 ;  Chicago,  1 :  580 ;  Washington,  1  :  270  ;  San  Francisco,  1  :  370.  These  ratios  are 
calculated  on  the  basis  of  figures  obtained  from  Folk's  Medical  Register,  the  American  Medical  Direc- 
tory, and  estimates  prepared  by  the  U.  S.  Census  Bureau.  The  force  of  the  figures  as  to  the  number 
of  physicians  cannot  be  broken  by  urging  that  many  physicians  no  longer  practise.  Such  have  been 
carefully  excluded  by  the  compilers  of  the  American  Medical  Directory.  Figures  used  throughout 
this  report  were  obtained  from  these  sources. 

3  Examples  may  be  cited  at  random  from  every  section  of  the  country  in  proof  of  the  fact  that  over- 
crowding is  general,  not  merely  local  or  exceptional,  e.g. : 


Ohio: 


Killbrook,  population  807.  has  three  doctors 


Houston 

227 

• 

Texas:                Wellington 

87 

five 

Whitt 

378 

four 

Whitney 

7M 

•ix 

Massachusetts:  Colerain 

80 

two 

Harding 

100 

U 

Nebraska:           Eustin 

292 

* 

Crofton 

40 

u 

Oregon:               K..-,il 

870 

U. 

Oaston 

182 

• 

(Prom  the  American  Medical  Directory.  1000.) 


HISTORICAL  AND  GENERAL  15 

In  the  country  the  situation  follows  one  of  two  types.  Assuming  that  a  thousand 
people  in  an  accessible  area  will  support  a  competent  physician,  one  of  two  things 
will  happen  if  the  district  contains  many  less.  In  a  growing  country,  like  Canada 
or  our  own  middle  west,  the  young  graduate  will  not  hesitate  to  pitch  his  tent  in  a 
sparsely  settled  neighborhood,  if  it  promises  a  future.  A  high-grade  and  comparatively 
expensive  education  will  not  alter  his  inclination  to  do  this.  The  more  exacting 
Canadian  laws  rouse  no  objection  on  this  score.  The  graduates  of  McGill  and  Toronto 
have  passed  through  a  scientific  and  clinical  discipline  of  high  quality ;  but  one  finds 
them  every  year  draining  off  into  the  freshly  opened  Northwest  Territory.  In  truth, 
it  is  an  old  story.  McDowell  left  the  Kentucky  backwoods  to  spend  two  years  under 
Bell  in  Edinburgh;  and  when  they  were  over,  returned  contentedly  to  the  wilderness, 
where  he  originated  the  operation  for  ovarian  tumor  in  the  course  of  a  surgical 
practice  that  carried  him  back  and  forth  through  Kentucky,  Ohio,  and  Tennessee. 
Benjamin  Dudley,  son  of  a  poor  Baptist  preacher,  dissatisfied  with  the  results  first  of 
his  apprenticeship,  then  of  his  Philadelphia  training,  hoarded  his  first  fees,  and  with 
them  subsequently  embarked  temporarily  in  trade ;  he  loaded  a  flat-boat  with  sun- 
dries, which  he  disposed  of  to  good  advantage  at  New  Orleans,  there  investing  in  a 
cargo  of  flour,  which  he  sold  to  the  hungry  soldiers  of  Wellington  in  the  Spanish 
peninsula.  The  profits  kept  Dudley  in  the  hospitals  of  Paris  for  four  years,  after 
which  he  came  back  to  Lexington,  and  for  a  generation  was  the  great  surgeon  and 
teacher  of  surgery  in  the  rough  country  across  the  Alleghanies.  The  pioneer  is  not 
yet  dead  within  us.  The  self-supporting  students  of  Ann  Arbor  and  Toronto  prove 
this.  For  a  region  which  holds  out  hope,  there  is  no  need  to  make  poor  doctors,  — 
still  less  to  make  too  many  of  them. 

In  the  case  of  stranded  small  groups  in  an  unpromising  environment  the  thing 
works  out  differently.  A  century  of  reckless  over-production  of  cheap  doctors  has  re- 
sulted in  general  overcrowding;  but  it  has  not  forced  doctors  into  these  hopeless 
spots.  It  has  simply  huddled  them  thickly  at  points  on  the  extreme  margin.  Certain 
rural  communities  of  New  England  may,  for  example,  have  no  physician  in  their 
midst,  though  they  are  in  most  instances  not  inaccessible  to  one.  But  let  never  so 
many  low-grade  doctors  be  turned  out,  whether  in  Boston  or  in  smaller  places  like 
Burlington  or  Brunswick,  that  are  supposed  not  to  spoil  the  young  man  for  a 
country  practice,  these  unpromising  places,  destined  perhaps  to  disappear  from  the 
map,  will  not  attract  them.  They  prefer  competition  in  some  already  over-occupied 
field.  Thus,  in  Vermont,  Burlington,  the  seat  of  the  medical  department  of  the  Uni- 
versity of  Vermont,  with  a  population  of  less  than  21,000,  has  60  physicians,  one  for 
every  333  inhabitants;1  nor  can  these  figures  be  explained  away  on  the  ground  that 
the  largest  city  in  the  state  is  a  vortex  which  absorbs  more  than  its  proper  share; 
for  the  state  abounds  in  small  towns  in  which  several  doctors  compete  in  the  service 
of  less  than  a  thousand  persons:  Post  Mills,  with  105  inhabitants,  has  two  doctors ; 
1  American  Medical  Directory;  Polk  (1908)  gives  75  active  physicians,  a  ratio  of  1 :280. 


16  MEDICAL  EDUCATION 

Jeffersonville,  with  400,  has  two;  Plainfield,  with  341,  has  three.  Other  New  England 
states  are  in  the  same  case.  It  would  appear,  then,  that  over-production  on  a  low 
basis  does  not  effectually  overcome  the  social  or  economic  obstacles  to  spontaneous 
dispersion.  Perhaps  the  salvation  of  these  districts  might,  under  existing  circum- 
stances, be  better  worked  out  by  a  different  method.  A  large  area  would  support  one 
good  man,  where  its  separate  fragments  are  each  unable  to  support  even  one  poor 
man.  A  physician's  range,  actual  and  virtual,  increases  with  his  competency.  A  well 
qualified  doctor  may  perhaps  at  a  central  point  set  up  a  small  hospital,  where  the 
seriously  ill  of  the  entire  district  may  receive  good  care.  The  region  is  thus  better 
served  by  one  well  trained  man  than  it  could  possibly  be  even  if  over-production  on 
a  low  basis  ultimately  succeeded  in  forcing  an  incompetent  into  every  hamlet  of  five 
and  twenty  souls.  This  it  cannot  compel.  It  cannot  keep  even  the  cheap  man  in  a 
place  without  a  "chance;"  it  can  only  demoralize  the  smaller  places  which  are  ca- 
pable of  supporting  a  better  trained  man  whose  energies  may  also  reach  out  into  the 
more  thinly  settled  surrounding  country.  As  a  last  resort,  it  might  conceivedly  be- 
come the  duty  of  the  several  states  to  salary  district  physicians  in  thinly  settled  or 
remote  regions,  —  surely  a  sounder  policy  than  the  demoralization  of  the  entire  pro- 
fession for  the  purpose  of  enticing  ill  trained  men  where  they  will  not  go.1  We  may 
safely  conclude  that  our  methods  of  carrying  on  medical  education  have  resulted  in 
enormous  over-production  at  a  low  level,  and  that,  whatever  the  justification  in  the 
past,  the  present  situation  in  town  and  country  alike  can  be  more  effectively  met  by  a 
reduced  output  of  well  trained  men  than  by  further  inflation  with  an  inferior  product. 
The  improvement  of  medical  education  cannot  therefore  be  resisted  on  the  ground 
that  it  will  destroy  schools  and  restrict  output :  that  is  precisely  what  is  needed.  The 
illustrations  already  given  in  support  of  this  position  may  be  reinforced  by  further 
examples  from  every  section  of  the  Union, — from  Pennsylvania  with  one  doctor  for 
every  636  inhabitants,  Maryland  with  one  for  every  658,  Nebraska  with  one  for  every 
602,  Colorado  with  one  for  every  328,  Oregon  with  one  for  every  646.  It  is  frequently 
urged  that,  however  applicable  to  other  sections,  this  argument  does  not  for  the  pre- 
sent touch  the  south,  where  continued  tolerance  of  commercial  methods  is  required 
by  local  conditions.  Let  us  briefly  consider  the  point.  The  section  as  a  whole  contains 
one  doctor  for  every  760  persons.  In  the  year  1908,  twelve  states2  showed  a  gain  in 
population  of  358,837.  If  now  we  allow  in  cities  one  additional  physician  for  every 
increase  of  2000,  and  outside  cities  an  additional  one  for  every  increase  of  1000  in 
population, — an  ample  allowance  in  any  event, — we  may  in  general  figure  on  one  more 
physician  for  every  gain  of  1500  in  total  population.  We  are  not  now  arguing  that 
a  ratio  of  1 : 1500  is  correct;  we  are  under  no  necessity  of  proving  that.  Our  conten- 

1  These  officials  would  combine  the  duties  of  county  health  officer  with  those  now  assigned  in  large 
towns  to  the  city  physician. 

'This  includes  Kentucky,  Virginia,  Tennessee,  North  Carolina,  South  Carolina,  Georgia,  Florida, 
Alabama,  Mississippi,  Louisiana,  Texas,  Arkansas. 


HISTORICAL  AND  GENERAL  17 

tion  is  simply  that,  starting  with  our  present  overcrowded  condition,  production 
henceforth  at  the  ratio  of  one  physician  to  every  increase  of  1500  in  population  will 
prevent  a  shortage,  for  the  next  generation  at  least.  In  1908  the  south,  then,  needed 
240  more  doctors  to  take  care  of  its  increase  in  population.  In  the  course  of  the  same 
year,  it  is  estimated  that  500  vacancies  in  the  profession  were  due  to  death.1  If  every 
vacancy  thus  arising  must  be  filled,  conditions  will  never  improve.  Let  us  agree  to  work 
towards  a  more  normal  adjustment  by  filling  two  vacancies  due  to  death  with  one  new 
physician, — once  more,  a  decidedly  liberal  provision.  This  will  prove  sufficiently  de- 
liberate; it  would  have  called  for  250  more  doctors  by  the  close  of  the  year.  In  all, 
490  new  men  would  have  amply  cared  for  the  increase  in  population  and  the  vacancies 
due  to  death.  As  a  matter  of  fact,  the  southern  medical  schools  turned  out  in  that  year 
1144  doctors;  78  more  southerners  were  graduated  from  the  schools  of  Baltimore  and 
Philadelphia.  The  grand  total  would  probably  reach  1300, — 1300  southern  doctors  to 
compete  in  a  field  in  which  one- third  of  the  number  would  find  the  making  of  a  decent 
living  already  difficult.  Clearly,  the  south  has  no  cause  to  be  apprehensive  inconsequence 
of  a  reduced  output  of  higher  quality.2  Its  requirements  in  the  matter  of  a  fresh  sup- 
ply are  not  such  as  to  make  it  necessary  to  pitch  their  training  excessively  low. 

The  rest  of  the  country  may  be  rapidly  surveyed  from  the  same  point  of  view. 
The  total  gain  in  population,  outside  the  southern  states  already  considered,  was 
975,008, — requiring  on  the  basis  of  one  more  doctor  for  every  1500  more  people, 
650  doctors.  By  death,  in  the  course  of  the  year  there  were  in  the  same  area  1730 
vacancies.  Replacing  two  vacancies  by  one  doctor,  865  men  would  have  been  re- 
quired ;  in  most  sections  public  interest  would  be  better  cared  for  if  they  all  remained 
unfilled  for  a  decade  to  come.  On  the  most  liberal  calculation,  1500  graduates  would 
be  called  for,  and  1000  would  be  better  still.  There  were  actually  produced  in  that 
year,  outside  the  south,  3497,  i.e.,  between  two  and  three  times  as  many  as  the  country 
could  possibly  assimilate;  and  this  goes  on,  and  has  been  going  on,  every  year. 

It  appears,  then,  that  the  country  needs  fewer  and  better  doctors;  and  that  the 
way  to  get  them  better  is  to  produce  fewer.  To  support  all  or  most  present  schools 
at  the  higher  level  would  be  wasteful,  even  if  it  were  not  impracticable;  for  they  can- 

1  Based  on  figures  collected  by  the  American  Medical  Association. 

2  As  Kentucky  is  one  of  the  largest  producers  of  low-grade  doctors  in  the  entire  Union,  it  is  interest- 
ing to  observe  conditions  there.  The  following  is  the  result  of  a  careful  study  of  Henderson  County 
made  for  me  by  one  thoroughly  acquainted  with  it. 

Total  population,  35,000 ;  number  of  doctors,  56 ;  ratio,  1 : 624. 

DISTRIBUTION 
Place 

City  of  Henderson 
Anthaston 
Baskett 
Cairo 
Corydon 
Dixie 
Geneva 
Hebardsville 

Throughout  the  county  there  are  doctors  within  five  miles  everywhere. 


Population 

No.  Drs.       1 

tatio 

Place 

Population 

No.  Drs.        J 

*tatio 

17,500 

27                1 

1:644 

Zion 

250 

S 

:84 

24 

1                ] 

1:24 

Robards 

500 

9              1 

:  187 

200 

2 

:100 

Niagara 

100 

9 

:94 

200 

1 

:200 

McDonald's  Landing 

25 

1,000 

4 

:250 

Alzey 

25 

1 

:25 

900 

1 

:300 

Smith  Mills 

200 

9 

:«7 

100 

2 

:50 

Spottsville 

700 

9 

:294 

400 

2 

:200 

i 


18  MEDICAL  EDUCATION 

not  be  manned.  Some  day,  doubtless,  posterity  may  reestablish  a  school  in  some 
place  where  a  struggling  enterprise  ought  now  to  be  discontinued.  Towards  that 
remote  contingency  nothing  will,  however,  be  gained  by  prolonging  the  life  of  the 
existent  institution. 

The  statistics  just  given  have  never  been  compiled  or  studied  by  the  average 
medical  educator.  His  stout  asseveration  that  "the  country  needs  more  doctors"  is 
based  on  "the  letters  on  file  in  the  dean's  office,"  or  on  some  hazy  notion  respecting 
conditions  in  neighboring  states.  As  to  the  begging  letters:  selecting  a  thinly  set- 
tled region,  I  obtained  from  the  dean  of  the  medical  department  of  the  University 
of  Minnesota  a  list  of  the  localities  whence  requests  for  a  physician  have  recently 
come.  With  few  exceptions,  they  represent  five  states:1  fifty-nine  towns  in  Minne- 
sota want  a  doctor ;  but  investigation  shows  that  these  fifty-nine  towns  have  already 
one  hundred  and  forty-nine  doctors  between  them  !2  Forty-one  places  in  North  Dakota 
apply ;  they  have  already  one  hundred  and  twenty-one  doctors.  Twenty-one  applica- 
tions come  from  South  Dakota,  from  towns  having  already  forty-nine  doctors;  seven 
from  Wisconsin,  from  places  that  had  twenty -one  physicians  before  their  prayer  for 
more  was  made;  six  from  Iowa,  from  towns  that  had  seventeen  doctors  at  the  time. 
It  is  clear  that  the  files  of  the  deans  will  not  invalidate  the  conclusion  which  a  study 
of  the  figures  suggests.  They  are  more  apt  to  sustain  it:  for  the  requests  in  question 
are  less  likely  to  mean  "no  doctor"  than  poor  doctors,3 — a  distemper  which  con- 
tinued over-production  on  the  same  basis  can  only  aggravate,  and  which  a  change  to 
another  of  the  same  type  will  not  cure.  As  to  general  conditions,  no  case  has  been 
found  in  which  a  single  medical  educator  contended  that  his  own  vicinity  or  state 
is  in  need  of  more  doctors:  it  is  always  the  "next  neighbor."  Thus  the  District  of 
Columbia,  with  one  doctor  for  every  two  hundred  and  sixty-two  souls,  maintains 
two  low-grade  medical  schools.  "Do  you  need  more  doctors  in  the  District?"  was 
asked  of  one  of  the  deans.  "Oh,  no,  we  are  making  doctors  for  Maryland,  Virginia, 
and  Pennsylvania," — for  Maryland,  with  seven  medical  schools  of  its  own  and  one 
doctor  for  every  six  hundred  and  fifty-eight  inhabitants;  for  Virginia,  with  three 
medical  schools  of  its  own  and  one  doctor  for  every  nine  hundred  and  eighteen;  for 
Pennsylvania,  with  its  eight  schools  and  one  doctor  for  every  six  hundred  and  thirty- 
six  persons. 

With  the  over-production  thus  demonstrated,  the  commercial  treatment  of  medi- 
cal education  is  intimately  connected.  Low  standards  give  the  medical  schools  ac- 
cess to  a  large  clientele  open  to  successful  exploitation  by  commercial  methods.  The 

1  The  general  distribution  in  these  states  shows  that  over-production  prevails  in  new  states  as  in  old 
ones :  Minnesota  1 :  981 ;  South  Dakota  1 :  821 ;  Iowa  1 :  605;  North  Dakota  1 :  971 ;  Wisconsin  1 :  936. 

*  Ten  of  the  fifty-nine  were  without  registered  physicians ;  but  of  these  ten,  two  are  not  to  be  found 
on  the  map,  two  more  are  not  in  the  Postal  Guide;  of  the  other  six,  four  are  in  easy  reach  of  doctors ; 
two,  with  a  combined  population  of  one  hundred  and  fifty,  are  out  of  reach. 

8  Occasionally  these  applications,  which  create  the  impression  of  a  dearth,  come  from  apothecaries 
who  have  a  rear  office  to  rent,  a  physician  with  a  practice  to  sell,  etc. 


HISTORICAL  AND  GENERAL  19 

crude  boy  or  the  jaded  clerk  who  goes  into  medicine  at  this  level  has  not  been  moved 
by  a  significant  prompting  from  within;  nor  has  he  as  a  rule  shown  any  forethought 
in  the  matter  of  making  himself  ready.  He  is  more  likely  to  have  been  caught  drift- 
ing at  a  vacant  moment  by  an  alluring  advertisement  or  announcement,  quite  com- 
monly an  exaggeration,  not  infrequently  an  outright  misrepresentation.  Indeed,  the 
advertising  methods  of  the  commercially  successful  schools  are  amazing.1  Not  infre- 
quently advertising  costs  more  than  laboratories.  The  school  catalogues  abound  in 
exaggeration,  misstatement,  and  half-truths.3  The  deans  of  these  institutions  occasion- 
ally know  more  about  modern  advertising  than  about  modern  medical  teaching.  They 
may  be  uncertain  about  the  relation  of  the  clinical  laboratory  to  bedside  instruction ; 
but  they  have  calculated  to  a  nicety  which  "medium"  brings  the  largest  "return." 
Their  dispensary  records  may  be  in  hopeless  disorder;  but  the  card  system  by  which 
they  keep  track  of  possible  students  is  admirable.  Such  exploitation  of  medical  edu- 
cation, confined  to  schools  that  admit  students  below  the  level  of  actual  high  school 
graduation,  is  strangely  inconsistent  with  the  social  aspects  of  medical  practice.  The 
overwhelming  importance  of  preventive  medicine,  sanitation,  and  public  health 
indicates  that  in  modern  life  the  medical  profession  is  an  organ  differentiated  by  so- 
ciety for  its  own  highest  purposes,  not  a  business  to  be  exploited  by  individuals  ac- 
cording to  their  own  fancy.  There  would  be  no  vigorous  campaigns  led  by  enlight- 
ened practitioners  against  tuberculosis,  malaria,  and  diphtheria,  if  the  commercial 
point  of  view  were  tolerable  in  practice.  And  if  not  in  practice,  then  not  in  educa- 
tion. The  theory  of  state  regulation  covers  that  point.  In  the  act  of  granting  the 
right  to  confer  degrees,  the  state  vouches  for  them ;  through  protective  boards  it  still 
further  seeks  to  safeguard  the  people.  The  public  interest  is  then  paramount,  and 
when  public  interest,  professional  ideals,  and  sound  educational  procedure  concur 
in  the  recommendation  of  the  same  policy,  the  time  is  surely  ripe  for  decisive  action. 


1  One  school  offers  any  graduate  who  shall  have  been  in  attendance  three  years  a  European  trip. 

2  See  chapter  viii.,  "  Financial  Aspects  of  Medical  Education,"  especially  p.  135. 

3  A  few  instances  may  be  cited  at  random : 

Medical  Department,  University  of  Buffalo:  "The  dispensary  is  conducted  in  a  manner  unlike  that 
usually  seen.  .  .  .  Each  one  will  secure  unusually  thorough  training  in  taking  and  recording  of  his- 
tories (p.  25).  There  are  no  dispensary  records  worthy  the  name. 

Halifax  Medical  College:  "First-class  laboratory  accommodation  is  provided  for  histology,  bacte- 
riology and  practical  pathology"  (p.  9).  One  utterly  wretched  room  is  provided  for  all  three. 

Medical  Department,  University  of  Illinois:  "The  University  Hospital ...  contains  one  hundred 
beds,  and  its  clinical  advantages  are  used  exclusively  for  the  students  of  this  college "  (p.  56).  Over 
half  of  these  beds  are  private,  and  the  rest  are  of  but  limited  use. 

Western  University  (London,  Ontario):  Clinical  instruction.  "The  Victoria  Hospital  .  .  .  now  con- 
tains two  hundred  and  fifty  beds,  and  is  the  official  hospital  of  the  City  of  London,"  etc.  (p.  14).  On 
the  average,  less  than  thirty  of  these  beds  are  available  for  teaching. 

The  Medical  Department  of  the  University  of  Chattanooga :  "The  latest  advances"  are  taught  "in 
the  most  entertaining  and  instructive  manner;"  professors  are  "chosen  for  their  proficiency ;'  "spec- 
ulative research  pertains  "  to  the  department  of  physiology  ;  the  department  of  pathology  is  "  pro- 
vided with  a  costly  collection  of  specimens  and  generous  supply  of  the  best  microscopes  (one,  as  a 
matter  of  fact);  "  the  hospitals  afford  numerous  cases  of  labor'  ! 


CHAPTER  II 

THE  PROPER  BASIS  OF  MEDICAL  EDUCATION 

WE  have  in  the  preceding  chapter  briefly  indicated  three  stages  in  the  develop- 
ment of  medical  education  in  America, — the  preceptorship,  the  didactic  school, 
the  scientific  discipline.  We  have  seen  how  an  empirical  training  of  varying 
excellence,  secured  through  attendance  on  a  preceptor,  gave  way  to  the  didactic 
method,  which  simply  communicated  a  set  body  of  doctrines  of  very  uneven  value; 
how  in  our  own  day  this  didactic  school  has  capitulated  to  a  procedure  that  seeks, 
as  far  as  may  be,  to  escape  empiricism  in  order  to  base  the  practice  of  medicine  on 
observed  facts  of  the  same  order  and  cogency  as  pass  muster  in  other  fields  of  pure 
and  applied  science.  The  apprentice  saw  disease;  the  didactic  pupil  heard  and  read 
about  it;  now  once  more  the  medical  student  returns  to  the  patient,  whom  in  the 
main  he  left  when  he  parted  with  his  preceptor.  But  he  returns,  relying  no  longer 
altogether  on  the  senses  with  which  nature  endowed  him,  but  with  those  senses  made 
infinitely  more  acute,  more  accurate,  and  more  helpful  by  the  processes  and  the  in- 
struments which  the  last  half-century's  progress  has  placed  at  his  disposal.  This  is 
the  meaning  of  the  altered  aspect  of  medical  training :  the  old  preceptor,  be  he  never 
so  able,  could  at  best  feel,  see,  smell,  listen,  with  his  unaided  senses.  His  achieve- 
ments are  not  indeed  to  be  lightly  dismissed;  for  his  sole  reliance  upon  his  senses 
greatly  augmented  their  power.  Succeed  as  he  might,  however,  his  possibilities  in  the 
way  of  reducing,  differentiating,  and  interpreting  phenomena,  or  significant  aspects 
of  phenomena,  were  abruptly  limited  by  his  natural  powers.  These  powers  are  nowa- 
days easily  enough  transcended.  The  self-registering  thermometer,  the  stethoscope,  the 
microscope,  the  correlation  of  observed  symptoms  with  the  outgivings  of  chemical 
analysis  and  biological  experimentation,  enormously  extend  the  physician's  range. 
He  perceives  more  speedily  and  more  accurately  what  he  is  actually  dealing  with; 
he  knows  with  far  greater  assurance  the  merits  or  the  limitations  of  the  agents  which 
he  is  in  position  to  invoke.  Though  the  field  of  knowledge  and  certainty  is  even  yet 
far  from  coextensive  with  the  field  of  disease  and  injury,  it  is,  as  far  as  it  goes,  open 
to  quick,  intelligent,  and  effective  action. 

Provided,  of  course,  the  physician  is  himself  competent  to  use  the  instrumentali- 
ties that  have  been  developed!  There  is  just  now  the  rub.  Society  reaps  at  this  mo- 
ment but  a  small  fraction  of  the  advantage  which  current  knowledge  has  the  power 
to  confer.  That  sick  man  is  relatively  rare  for  whom  actually  all  is  done  that  is  at 
this  day  humanly  feasible, — as  feasible  in  the  small  hamlet  as  in  the  large  city,  in 
the  public  hospital  as  in  the  private  sanatorium.  We  have  indeed  in  America  medi- 
cal practitioners  not  inferior  to  the  best  elsewhere;  but  there  is  probably  no  other 
country  in  the  world  in  which  there  is  so  great  a  distance  and  so  fatal  a  difference 
between  the  best,  the  average,  and  the  worst. 


PROPER  BASIS  OF  MEDICAL  EDUCATION  21 

The  attempt  will  be  made  in  this  chapter  and  the  next  to  account  for  these  dis- 
crepancies in  so  far  as  they  are  traceable  to  circumstances  that  antedate  the  formal 
beginning  of  medical  education  itself.  The  mastery  of  the  resources  of  the  profession 
in  the  modern  sense  is  conditioned  upon  certain  definite  assumptions,  touching  the 
medical  student's  education  and  intelligence.  Under  the  apprentice  system,  it  was  not 
necessary  to  establish  any  such  general  or  uniform  basis.  The  single  student  was  in 
personal  contact  with  his  preceptor.  If  he  were  young  or  immature,  the  preceptor 
could  wait  upon  his  development,  initiating  him  in  simple  matters  as  they  arose, 
postponing  more  difficult  ones  to  a  more  propitious  season ;  meanwhile,  there  were 
always  the  horses  to  be  curried  and  the  saddle-bags  to  be  replenished.  In  the  end,  if 
the  boy  proved  incorrigibly  dull,  the  perceptor  might  ignore  him  till  a  convenient 
excuse  discontinued  the  relation.  During  the  ascendancy  of  the  didactic  school,  it  was 
indeed  essential  to  good  results  that  lecturers  and  quizmasters  should  be  able  to 
gauge  the  general  level  of  their  huge  classes ;  but  this  level  might  well  be  low,  and 
in  the  common  absence  of  conscientiousness  usually  fell  far  below  the  allowable 
minimum.  In  any  event,  the  student's  part  was,  parrot-like,  to  absorb.  His  medical 
education  consisted  largely  in  getting  by  heart  a  prearranged  system  of  correspon- 
dences,— an  array  of  symptoms  so  set  off  against  a  parallel  array  of  doses  that, 
if  he  noticed  the  one,  he  had  only  to  write  down  the  other:  a  coated  tongue — a 
course  of  calomel;  a  shivery  back — a  round  of  quinine.  What  the  student  did  not 
readily  apprehend  could  be  drilled1  into  him  —  towards  examination  time  —  by 
those  who  had  themselves  recently  passed  through  the  ordeal  which  he  was  now 
approaching;  and  an  efficient  apparatus  that  spared  his  senses  and  his  intellect  as 
entirely  as  the  drillmaster  spared  his  industry  was  readily  accessible  at  tempt- 
ingly low  prices  in  the  shape  of  "essentials"  and  "quiz-compends."  Thus  he  got,  and 
in  places  still  gets,  his  materia  medica,  anatomy,  obstetrics,  and  surgery.  The  med- 
ical schools  accepted  the  situation  with  so  little  reluctance  that  these  compends 
were — and  occasionally  still  are — written  by  the  professors2  and  sold  on  the  pre- 

1"A  reiteration  of  undisputed  facts  in  their  simplest  expression,"  is  Bigelow's  way  of  putting  it.  Loe. 
cit.,  p.  11. 

2  From  the  last  catalogues  of  certain  medical  publishers : 

"  QUIZ-COMPENDS  : " 

Physiology,  by  A.  P.  Brubaker,  Professor  of  Physiology,  Jefferson  Medical  College,  Philadelphia. 

Oynecology,  by  Wm.  H.  Wells,  Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  College, 

Philadelphia. 

Surgery,  by  Orville  Horwitz,  Prof,  of  Genito-Urinary  Surgery,  Jefferson  Medical  College,  Philadelphia. 

Diseases  of  Children,  by  Marcus  P.  Hatfield,  Professor  of  Diseases  of  Children,  Chicago  Medical  College. 

Special  Pathology,  by  A.  E.  Thayer,  Professor  of  Pathology,  University  of  Texas. 

"ESSENTIALS:" 

Surgery,  by  Edward  Martin,  Professor  of  Clinical  Surgery,  University  of  Pennsylvania. 

Anatomy,  by  C.  B.  Nancrede,  Professor  of  Surgery,  University  of  Michigan. 

Obstetrics,  by  W.  E.  Ashton,  Professor  of  Gynecology,  Medico-Chirurgical  College,  Philadelphia. 

Oynecology,  by  E.  B.  Cragin,  Professor  of  Obstetrics,  Columbia  University. 

Histology,  by  Louis  Leroy,  Professor  of  Medicine,  College  of  Physicians  and  Surgeons,  Memphis. 

Diseases  of  the  Skin,  by  H.  W.  Stelwagon,  Prof,  of  Dermatology,  Jefferson  Medical  College,  Phila. 

Diseases  of  the  Eye,  by  Edward  Jackson,  Professor  of  Ophthalmology,  University  of  Colorado. 


22  MEDICAL  EDUCATION 

raises.1  Under  such  a  regime  anybody  could,  as  President  Eliot  remarked,  "walk  into 
a  medical  school  from  the  street,"  and  small  wonder  that  of  those  who  did  walk  in, 
many  "could  barely  read  and  write."2  But  with  the  advent  of  the  laboratory,  in  which 
every  student  possesses  a  locker  where  his  individual  microscope,  reagents,  and  other 
paraphernalia  are  stored  for  his  personal  use;  with  the  advent  of  the  small  group  bed- 
side clinic,  in  which  every  student  is  responsible  for  a  patient's  history  and  for  a  trial 
diagnosis,  suggested,  confirmed,  or  modified  by  his  own  microscopical  and  chemical 
examination  of  blood,  urine,  sputum,  and  other  tissues,  the  privileges  of  the  medical 
school  can  no  longer  be  open  to  casual  strollers  from  the  highway.  It  is  necessary  to 
install  a  doorkeeper  who  will,  by  critical  scrutiny,  ascertain  the  fitness  of  the  appli- 
cant: a  necessity  suggested  in  the  first  place  by  consideration  for  the  candidate, 
whose  time  and  talents  will  serve  him  better  in  some  other  vocation,  if  he  be  unfit 
for  this;  and  in  the  second,  by  consideration  for  a  public  entitled  to  protection  from 
those  whom  the  very  boldness  of  modern  medical  strategy  equips  with  instruments 
that,  tremendously  effective  for  good  when  rightly  used,  are  all  the  more  terrible 
for  harm  if  ignorantly  or  incompetently  employed. 

A  distinct  issue  is  here  presented.  A  medical  school  may,  the  law  permitting,  eschew 
clinics  and  laboratories,  cling  to  the  didactic  type  of  instruction,  and  arrange  its 
dates  so  as  not  to  conflict  with  seedtime  and  harvest ;  or  it  may  equip  laboratories, 
develop  a  dispensary,  and  annex  a  hospital,  pitching  its  entrance  requirements  on  a 
basis  in  keeping  with  its  opportunities  and  pretensions.  But  it  cannot  consistently 
open  the  latter  type  of  school  to  the  former  type  of  student.  It  cannot  provide 
laboratory  and  bedside  instruction  on  the  one  hand,  and  admit  crude,  untrained  boys 
on  the  other.  The  combination  is  at  once  illogical  and  futile.  The  funds  of  the  school 
may  indeed  procure  facilities;  but  the  intelligence  of  the  students  can  alone  ensure 
their  proper  use.  Nor  can  the  dilemma  be  evaded  by  alleging  that  a  small  amount 
of  laboratory  instruction  administered  to  an  unprepared  medical  student  makes  a 
"practitioner,"  while  the  more  thorough  training  of  a  competent  man  makes  a  "sci- 
entist."* At  the  level  at  which  under  the  most  favorable  circumstances  the  medical 
student  gets  his  education,  it  is  absurd  to  speak  of  an  inherent  conflict  between  science 
and  practice.  We  shall  have  occasion  later  to  touch  on  the  relation  of  teaching  and 

1  For  example,  in  the  Atlanta  College  of  Physicians  and  Surgeons ;  Medical  Department,  University 
of  Nashville ;  North  Carolina  Medical  College  (Charlotte);  Medical  Department,  University  of  Pitts- 
burgh; John  A.  Creighton  Medical  College  (Omaha,  Nebraska);  Starling-Ohio  Medical  College 
(Columbus);  George  Washington  University  (D.  C.). 

2The  American  Medical  Asiociation  Bulletin,  vol.  iii.,  no.  5,  p.  262. 

*  At  a  medical  convention  recently  held,  a  professor  in  an  institution  on  the  basis  of  a  "high  school 
education  or  its  equivalent,"  made  this  point  in  a  speech,  as  against  the  medical  department  of 
a  university,  which  requires  for  entrance  college  work:  TTie  lower-grade  institution  made  "doctors,"  it 
was  averred;  the  higher  made  only  "  scientists."  Now  it  chances  that  for  the  last  two  years  both  sets 
of  students  have  submitted  to  a  practical  examination  in  subjects  like  urinalysis,  which  assuredly  it 
behooves  the  "doctor"  as  well  as  the  "scientist"  to  master.  At  these  examinations  the  "doctors" 
show  an  average  of  59  percent;  the  "scientists,"  77  per  cent.  On  the  combined  written  and  practical 
examinations  this  year,  the  "doctors"  in  question  averaged  65.2  per  cent,  the  "scientists"  averaged 
83.1  percent. 


PROPER  BASIS  OF  MEDICAL  EDUCATION  23 

research,1  between  which  it  is  necessary  to  establish  a  modus  Vivendi.  But  that  pro- 
blem has  nothing  to  do  with  the  point  now  under  discussion, — viz.,  as  to  how  much 
education  or  intelligence  it  requires  to  establish  a  reasonable  presumption  of  fitness 
to  undertake  the  study  of  medicine  under  present  conditions. 

Taking,  then,  modern  medicine  as  an  attempt  to  fight  the  battle  against  disease 
most  advantageously  to  the  patient,  what  shall  we  require  of  those  who  propose  to 
enlist  in  the  service?  To  get  a  somewhat  surer  perspective  in  dealing  with  a  ques- 
tion around  which  huge  clouds  of  dust  have  been  beaten  up,  let  us  for  a  moment 
look  elsewhere.  A  college  education  is  not  in  these  days  a  very  severe  or  serious  dis-  -4 — 
cipline.  It  is  compounded  in  varying  proportions  of  work  and  play;  it  scatters  I 
whatever  effort  it  requires,  so  that  at  no  point  need  the  student  stand  the  strain  of 
prolonged  intensive  exertion.  Further,  the  relation  of  college  education  to  specific 
professional  or  vocational  competency  is  still  under  dispute.  It  is  clear,  then,  that  a 
college  education  is  less  difficult,  less  trying,  less  responsible,  than  a  professional  edu- 
cation in  medicine.  It  is  therefore  worth  remarking  that  the  lowest  terms  upon  which 
a  college  education  is  now  regularly  accessible  are  an  actual  four-year  high  school 
training,  scholastically  determined,  whether  by  examination  of  the  candidate  or  by 
appraisement  of  the  school. 

Technical  schools  of  engineering  and  the  mechanic  arts  afford  perhaps  an  even 
more  illuminating  comparison.  These  institutions  began,  like  the  college,  at  a  low 
level;  but  they  did  not  long  rest  there.  Their  instruction  was  too  heavily  handicapped 
by  ignorance  and  immaturity.  To  their  graduates,  tasks  involving  human  life  and 
welfare  were  committed :  the  building  of  bridges,  the  installation  of  power  plants, 
the  construction  of  sewage  systems.  The  technical  school  was  thus  driven  to  seek  stu- 
dents of  greater  maturity,  of  more  thorough  preliminary  schooling,  and  strictly  to 
confine  its  opportunities  to  them.  Now  it  is  noteworthy  that,  though  in  point  of  in- 
tensive strain  the  discipline  of  the  modern  engineer  equals  the  discipline  of  the  mod- 
ern physician,  in  one  important  respect,  at  least,  it  is  less  complex  and  exacting. 
The  engineer  deals  mainly  with  measurable  factors.  His  factor  of  uncertainty  is  within 
fairly  narrow  limits.  The  reasoning  of  the  medical  student  is  much  more  complicated. 
He  handles  at  one  and  the  same  time  elements  belonging  to  vastly  different  cate- 
gories :  physical,  biological,  psychological  elements  are  involved  in  each  other.  More- 
over, the  recent  graduate  in  engineering  is  not  at  once  exposed  to  a  decisive  respon- 
sibility ;  to  that  he  rises  slowly  through  a  lengthy  series  of  subordinate  positions  that 
search  out  and  complete  his  education.2  Between  the  young  graduate  in  medicine 
and  his  ultimate  responsibility — human  life — nothing  interposes.  He  cannot  now- 
adays begin  with  easy  tasks  under  the  surveillance  of  a  superior;  the  issues  of  life 

1  See  page  55. 

2  It  is  interesting  to  observe  the  tendency  towards  conferring  only  a  bachelor's  degree  in  engineering 
at  graduation  instead  of  the  degree  of  C.E.,  etc.  The  bachelor  in  engineering  usually  goes  to  work 
at  laborer's  wages ;  he  is  years  reaching  the  degree  of  responsibility  with  which  the  graduate  in  med- 
icine usually  begins. 


24  MEDICAL  EDUCATION 

and  death  are  all  in  the  day's  work  for  him  from  the  very  first.  The  training  of  the 
doctor  is  therefore  more  complex  and  more  directly  momentous  than  that  of  the 
technician.  Be  rt  noted,  then,  that  the  minimum  basis  upon  which  a  good  school  of 
engineering  to-day  accepts  students  is,  once  more,  an  actual  high  school  education, 
and  that  the  movement  towards  elongating  the  technical  course  to  five  years  con- 
fesses the  urgent  need  of  something  more. 

There  is  another  aspect  of  the  problem  equally  significant.  The  curriculum  of  the 
up-to-date  technical  school  is  heavily  weighted,  to  be  sure;  but  except  for  mathema- 
tics, the  essential  subjects  with  which  it  starts  are  separate  sciences  that  presuppose 
no  prior  mastery  of  contributory  sciences.  Take  at  random  the  College  of  Engi- 
neering of  the  University  of  Wisconsin.  In  the  first  year  the  science  work  is  chem- 
istry, and  though  the  course  is  difficult,  it  demands  no  preceding  acquaintance  with 
chemistry  itself  or  with  any  other  science;  second-year  physics  is  in  the  same  case, 
and  the  mechanics  of  the  second  semester  looks  back  no  further  than  to  the  physics 
of  the  first. 

Very  different  is  the  plight  of  the  medical  school.  There  the  earliest  topics  of  the 
curriculum  proper — anatomy,  physiology,  physiological  chemistry — already  hark 
back  to  a  previous  scientific  discipline.  Every  one  of  them  involves  already  acquired 
knowledge  and  manipulative  skill.  They  are  laboratory  sciences  at  the  second,  not 
the  primary,  stage.  Consider,  for  example,  anatomy,  the  simplest  and  most  funda- 
mental of  them  all.  It  used  to  begin  and  end  with  the  dissection  of  the  adult  cada- 
ver. It  can  neither  begin  nor  end  there  to-day ;  for  it  must  provide  the  basis  upon 
which  experimental  physiology,  pathology,  and  bacteriology  may  intelligently  be  built 
up.  Mere  dissection  does  not  accomplish  this;  in  addition  to  gross  anatomy,  the  stu- 
dent must  make  out  under  the  microscope  the  normal  cellular  structure  of  organ, 
muscle,  nerve,  and  blood-vessel;  he  must  grasp  the  whole  process  of  structural  de- 
velopment. Histology  and  embryology  are  thus  essential  aspects  of  anatomical  study. 
No  treatment  of  the  subject  including  these  is  possible  within  the  time-limits  of  the 
modern  medical  curriculum  unless  previous  training  in  general  biology  has  equipped 
the  student  with  the  necessary  fundamental  conceptions,  knowledge,  and  technical 
dexterity.  It  has  just  been  stated  that  physiology  presupposes  anatomy  on  lines  involv- 
ing antecedent  training  in  biology;  it  leans  just  as  hard  on  chemistry  and  physics. 
The  functional  activities  of  the  body  propound  questions  in  applied  chemistry  and 
applied  physics.  Nutrition  and  waste — what  are  these  but  chemical  problems  within 
the  realm  of  biology?  The  mechanism  of  circulation,  of  seeing,  or  hearing — what 
are  these  but  physical  problems  under  the  same  qualifications?  The  normal  rhythm 
of  physiological  function  must  then  remain  a  riddle  to  students  who  cannot  think 
and  speak  in  biological,  chemical,  and  physical  language. 

All  this  is,  however,  only  preliminary.  The  physician's  concern  with  normal  pro- 
cess is  not  disinterested  curiosity;  it  is  the  starting-point  of  his  effort  to  comprehend 
and  to  master  the  abnormal.  Pathology  and  bacteriology  are  the  sciences  concerned 


PROPER  BASIS  OF  MEDICAL  EDUCATION  25 

with  abnormalities  of  structure  and  function  and  their  causation.  Now  the  agents  and 
forces  which  invade  the  body  to  its  disadvantage  play  their  game,  too,  according  to 
law.  And  to  learn  that  law  one  goes  once  more  to  the  same  fundamental  sciences 
upon  which  the  anatomist  and  the  physiologist  have  already  freely  drawn, — viz.,  bi- 
ology, physics,  and  chemistry. 

Nor  do  these  apparently  recondite  matters  concern  only  the  experimenting  investi- 
gator, eager  to  convert  patiently  acquired  knowledge  of  bacterial  and  other  foes  into 
a  rational  system  of  defense  against  them.  For  the  practical  outcome  of  such  investiga- 
tion is  not  communicable  by  rote;  it  cannot  be  reduced  to  prescriptions  for  mechan- 
ical use  by  the  unenlightened  practitioner.  Modern  medicine  cannot  be  formulated 
in  quiz-compends;  those  who  would  employ  it  must  trouble  to  understand  it.  More- 
over, medicine  is  developing  with  beneficent  rapidity  along  these  same  biological 
and  chemical  lines.  Is  our  fresh  young  graduate  of  five  and  twenty  to  keep  abreast 
of  its  progress?  If  so,  he  must,  once  more,  understand;  not  otherwise  can  he  adopt 
the  new  agents  and  new  methods  issuing  at  intervals  from  each  of  a  dozen  fertile 
laboratories;  for  rote  has  no  future:  it  stops  where  it  is.  "There  can  be  no  doubt," 
said  Huxley,  "that  the  future  of  pathology  and  of  therapeutics,  and  therefore  of 
practical  medicine,  depends  upon  the  extent  to  which  those  who  occupy  themselves 
with  these  subjects  are  trained  in  the  methods  and  impregnated  with  the  funda- 
mental truths  of  biology."1  Now  the  medical  sciences  proper — anatomy,  physiology, 
pathology,  pharmacology — already  crowd  the  two  years  of  the  curriculum  that  can 
be  assigned  to  them ;  and  in  so  doing,  take  for  granted  the  more  fundamental  sci- 
ences— biology,  physics,  and  chemistry — for  which  there  is  thus  no  adequate  op- 
portunity within  the  medical  school  proper.  Only  at  the  sacrifice  of  some  essential 
part  of  the  medical  curriculum — and  for  every  such  sacrifice  the  future  patients  pay 
— can  this  curriculum  be  made  to  include  the  preliminary  subjects  upon  which  it 
presumes. 

From  the  foregoing  discussion,  these  conclusions  emerge:  By  the  very  nature  of 
the  case,  admission  to  a  really  modern  medical  school  must  at  the  very  least  depend 
on  a  competent  knowledge  of  chemistry,  biology,2  and  physics.  Every  departure  from 
this  basis  is  at  the  expense  of  medical  training  itself.  From  the  exclusive  standpoint 
of  the  medical  school  it  is  immaterial  where  the  student  gets  the  instruction.  But  it 
is  clear  that  if  it  is  to  become  the  common  minimum  basis  of  medical  education,  some 
recognized  and  organized  manner  of  obtaining  it  must  be  devised :  it  cannot  be  left 
to  the  initiative  of  the  individual  without  greatly  impairing  its  quality.  Regular  pro- 
vision must  therefore  be  made  at  a  definite  moment  of  normal  educational  progress. 
Now  the  requirement  above  agreed  on  is  too  extensive  and  too  difficult  to  be  incor- 
porated in  its  entirety  within  the  high  school  or  to  be  substituted  for  a  considerable 

1  Quoted  by  F.  T.  Lewis  in  "  The  Preparation  for  the  Study  of  Medicine,"  Popular  Science  Monthly, 
vol.  Ixxv.,  no.  1,  p.  66. 

2  Including  botany. 


26  MEDICAL  EDUCATION 

portion  of  the  usual  high  school  course ;  besides,  it  demands  greater  maturity  than 
the  secondary  school  student  can  be  credited  with  except  towards  the  close  of  his 
high  school  career.  The  possibility  of  mastering  the  three  sciences  outside  of  school 
may  be  dismissed  without  argument.  In  the  college  or  technical  school  alone  can  the 
work  be  regularly,  efficiently,  and  surely  arranged  for.  The  requirement  is  therefore 
necessarily  a  college  requirement,  covering  two  years,  because  three  laboratory  courses 
cannot  be  carried  through  in  a  briefer  period, — a  fortunate  circumstance,  since  it 
favors  the  student's  simultaneous  development  along  other  and  more  general  lines. 
It  appears,  then,  that  a  policy  that  at  the  outset  was  considered  from  the  narrow 
standpoint  of  the  medical  school  alone  shortly  involves  the  abandonment  of  this 
point  of  view  in  favor  of  something  more  comprehensive.  The  preliminary  require- 
ment for  entrance  upon  medical  education  must  therefore  be  formulated  in  terms 
that  establish  a  distinct  relation,  pedagogical  and  chronological,  between  the  medi- 
cal school  and  other  educational  agencies.  Nothing  will  do  more  to  steady  and  to 
improve  the  college  itself  than  its  assumption  of  such  definite  functions  in  respect 
to  professional  and  other  forms  of  special  training. 

So  far  we  have  spoken  explicitly  of  the  fundamental  sciences  only.  They  furnish, 
indeed,  the  essential  instrumental  basis  of  medical  education.  But  the  instrumental 
minimum  can  hardly  serve  as  the  permanent  professional  minimum.  It  is  even  in- 
strumentally  inadequate.  The  practitioner  deals  with  facts  of  two  categories.  Chem- 
istry, physics,  biology  enable  him  to  apprehend  one  set;  he  needs  a  different  ap- 
perceptive  and  appreciative  apparatus  to  deal  with  other,  more  subtle  elements. 
Specific  preparation  is  in  this  direction  much  more  difficult;  one  must  rely  for  the 
requisite  insight  and  sympathy  on  a  varied  and  enlarging  cultural  experience.  Such 
enlargement  of  the  physician's  horizon  is  otherwise  important,  for  scientific  progress 
has  greatly  modified  his  ethical  responsibility.  His  relation  was  formerly  to  his  pa- 
tient— at  most  to  his  patient's  family;  and  it  was  almost  altogether  remedial.  The 
patient  had  something  the  matter  with  him;  the  doctor  was  called  in  to  cure  it.  Pay- 
ment of  a  fee  ended  the  transaction.  But  the  physician's  function  is  fast  becoming 
social  and  preventive,  rather  than  individual  and  curative.  Upon  him  society  relies 
to  ascertain,  and  through  measures  essentially  educational  to  enforce,  the  conditions 
that  prevent  disease  and  make  positively  for  physical  and  moral  well-being.  It  goes 
without  saying  that  this  type  of  doctor  is  first  of  all  an  educated  man. 

How  nearly  our  present  resources — educational  and  economic — permit  us  to  ap- 
proach the  standards  above  defined  is  at  bottom  a  question' of  fact  to  be  investigated 
presently.  We  have  concluded  that  a  two-year  college  training,  in  which  the  sciences 
are  "featured,"  is  the  minimum  basis  upon  which  modern  medicine  can  be  success- 
fully taught.  If  the  requisite  number  of  physicians  cannot  at  one  point  or  another 
be  procured  at  that  level,  a  temporary  readjustment  may  be  required;  but  such  an 
expedient  is  to  be  regarded  as  a  makeshift  that  asks  of  the  sick  a  sacrifice  that  must 
not  be  required  of  them  a  moment  longer  than  is  necessary.  Before  accepting  such 


PROPER  BASIS  OF  MEDICAL  EDUCATION  27 

a  measure,  however,  it  is  exceedingly  important  not  to  confuse  the  basis  on  which 
society  can  actually  get  the  number  of  doctors  that  it  needs  with  the  basis  on 
which  our  present  number  of  medical  schools  can  keep  going.  Much  depends  upon 
which  end  we  start  from. 


CHAPTER  III 

THE  ACTUAL  BASIS  OF  MEDICAL  EDUCATION 

TAKING  a  two-year  college  course,  largely  constituted  of  the  sciences,  as  the  normal 
point  of  departure,  let  us  now  survey  the  existing  status.  The  one  hundred  and  fifty- 
five  medical  schools  of  the  United  States  and  Canada  fall  readily  into  three  divisions: 
the  first  includes  those  that  require  two  or  more  years  of  college  work  for  entrance; 
the  second,  those  that  demand  actual  graduation  from  a  four-year  high  school  or 
oscillate  about  its  supposed  "equivalent;"  the  third,  those  that  ask  little  or  nothing 
more  than  the  rudiments  or  the  recollection  of  a  common  school  education. 

To  the  first  division  sixteen  institutions  already  belong;1  six  more,  now  demand- 
ing one  year  of  college  work,  will  fully  enter  the  division  in  the  fall  of  1910  by  re- 
quiring a  second;8  and  several  more,  at  this  date  still  in  the  second  division,  will 
shortly  take  the  step  from  the  high  school  to  the  two-year  college  requirement.3 
The  Johns  Hopkins  requires  for  entrance  a  college  degree  which,  whatever  else  it 
represents,  must  include  the  three  fundamental  sciences,  French,  and  German.  No 
exception  has  ever  been  made  to  this  degree  requirement ;  but  recently  admission  to 
the  second-year  class  has  been  granted  to  students  holding  an  A.B.  degree  earned 
by  four  years'  study,  the  last  of  them  devoted  to  medical  subjects  in  institutions 
where  those  subjects  were  excellently  taught.4  At  Harvard  the  degree  requirement 
has  been  somewhat  unsettled  by  a  recent  decision  to  admit  students  without  degree, 
provided  they  have  had  two  years  of  college  science ;  they  are  to  be  grouped  as  "  spe- 

1  Johns  Hopkins,  Harvard,  Western  Reserve,  Rush  (University  of  Chicago),  Cornell,  Stanford,  Wake 
Forest  (N.  C.),  Yale,  and  the  state  universities  of  California,  Minnesota,  North  Dakota,  Wisconsin, 
Michigan  (exclusive  of  the  homeopathic  department),  Kansas,  Nebraska,  South  Dakota. 

2  Universities  of  Indiana,  Iowa  (exclusive  of  the  homeopathic  department),  Missouri,  Pennsylvania, 
Utah,  Syracuse.  Several  institutions  ask  one  year  of  college  work,  without  as  yet  definite  announce- 
ment as  to  requirement  of  the  second,  e.g.,  Virginia,  Fordham,  Northwestern,  North  Carolina.  In 
general,  the  one-year  college  requirement  is  hard  to  distinguish  from  the  high  school  requirement, 
for  if  conditions  are  allowed,  —  and  they  always  are,  — it  adds  but  little  to  the  better  type  of  high  school 
education.  Northwestern  has  had  two  years  experience  under  the  one-year  college  requirement,  but 
has  not  yet  really  enforced  it.  The  University  of  North  Carolina  was  to  require  a  year  of  college  work, 
1909-10,  but  students  were  admitted  on  the  strength  of  their  unsupported  statements  "  as  having  had 
a  college  year.  .  .  .  Practically,  this  means  that  the  entrance  requirements  were  not  enforced." 

'Columbia,  Dartmouth,  Colorado. 

4  Practically,  this  amounts  to  a  recognition  of  the  A.B.  degree  won  after  three  years  of  study, — a 
movement  deserving  encouragement  rather  than  criticism,  as  matters  now  stand.  In  fact,  the  Johns 
Hopkins  degree  was  originally  conferred  at  the  close  of  three  years  of  study,  but  the  academic  ma- 
triculation requirement  was  considerably  higher  than  in  institutions  granting  the  A.B.  degree  after 
four  years  of  study.  Recently  the  academic  matriculation  has  been  lowered  and  the  A.B.  course 
lengthened  to  four  years.  In  consequence,  the  action  of  the  medical  department  above  described  in- 
volves unwittingly  a  curious  discrimination  against  the  Johns  Hopkins  A.B.  degree,  for  this  degree 
now  requires  four  years  and  may  not  include  medical  subjects.  To  get  the  Johns  Hopkins  M.D.,  a 
student  has  two  roads  open  to  him :  he  may  work  four  years  for  the  Johns  Hopkins  A.B.  and  four 
more  for  its  M.D., — eight  in  all;  or,  starting  at  exactly  the  same  point,  he  may  get  his  A.B.  in  four 
years  at  an  institution  that  includes  in  its  A.B.  the  first  year  in  medicine,  then  enter  the  Johns  Hop- 
kins medical  school  and  get  its  M.D.  in  three  years, — that  is,  seven  years  in  all.  A  B.S.  degree  earned 
in  three  years,  followed  by  the  M.D.  earned  in  four,  gives  the  same  result, — a  preference,  once  more, 
that  operates  against  the  Johns  Hopkins  A.B. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  29 

cial"  students,  and  are  required  to  maintain  higher  standing  in  order  to  qualify  for 
the  M.D.  degree.  But  as  these  students  enter  on  a  general  rule  and  as  a  matter  of 
course,  and  are,  under  a  slight  handicap,  eligible  to  the  M.D.  degree,  they  are  not 
accurately  described  as  special.  A  special  student  is  properly  one  whom  no  rule  fits, 
one  whose  admission  presents  certain  individual  features  requiring  consideration  on 
their  merits.  Such  is  not  the  case  with  the  students  under  discussion :  they  enter  just 
as  regularly  as  the  degree  men,  and  without  that  limitation  as  to  number  which 
makes  of  the  "special  student"  device  something  of  a  privilege.  Harvard  can  thus 
admit  any  student  who  is  eligible  to  the  schools  with  the  two-year  college  require- 
ment.1 The  other  institutions  under  discussion  telescope  the  college  and  medical 
courses:  the  preliminary  medical  sciences  constitute  the  bulk  of  two  college  years;1 
the  next  two  years  are  reckoned  twice.  They  count  simultaneously  as  third  and  fourth  1 
years  of  the  college  and  as  first  and  second  years  of  the  medical  course.  At  their  I 
close  the  student  gets  the  A.B.  degree,  but  his  medical  education  is  already  half 
over.  Without  exception,  the  schools  belonging  to  this  group  are  high-grade  institu- 
tions. They  differ  considerably,  however,  in  the  degree  of  rigor  with  which  their 
elevated  entrance  requirements  have  been  enforced  from  the  start.  At  the  University 
of  Pennsylvania,  for  example,  in  a  class  of  114,  admitted  this  year  (1909-10)  on  a  one- 
year  college  basis,  75  (66  per  cent)  are  conditioned;  at  Ann  Arbor,  of  36  entering  on 
the  two-year  college  basis,  only  8  are  conditioned  at  all,  and  those  mainly  in  organic 
chemistry;  at  Yale,  which  advanced  in  1909-10  from  the  high  school  to  the  two-year 
college  basis,  in  a  class  of  23,  there  was  only  one  partial  condition  in  biology,  and, 
best  of  all,  failed  members  of  last  year's  class  on  the  old  basis  were  refused  re-admis- 
sion. Experience  elsewhere  indicates  that  the  percentage  of  conditions  declines 
rapidly  as  students  learn  by  forethought  to  adjust  their  work  to  their  ultimate  pur- 
pose, and  as  the  colleges  facilitate  adjustment  by  providing  the  requisite  opportuni- 
ties: both  of  which  processes  will  be  accelerated,  if  the  medical  schools  have  the 
courage — and  the  financial  strength — to  close  their  doors  to  students  who  labor 
under  anything  more  than  a  slight  handicap.  Here  as  elsewhere  development  follows 
hard  upon  actual  responsibility. 

Our  second  division  constitutes  the  real  problem;  out  of  it  additional  high-grade 
medical  schools  to  the  number  actually  required  must  be  developed.  About  fifty  insti- 
tutions, whose  entrance  standard  approximates  high  school  graduation,  belong  here. 
Great  diversity  exists  in  the  quality  of  the  student  body  of  these  institutions :  the 
regents'  certificates  in  New  York,  state  board  supervision  in  Michigan,  the  control 
of  admission  to  their  medical  departments  by  the  academic  authorities  of  McGill 


1  The  rule  just  described  went  into  effect  1909-10 ;  two  students  took  advantage  of  it  in  a  class  of  62. 
In  1908  there  were  254  students  with  degrees,  23  without. 

2  Cornell,  Western  Reserve,  and  Stanford  combine  academic  and  college  courses  to  the  extent  of 
one  year  only.  The  pedagogical  aspect  of  the  combined  course  is  discussed  pp.  73,  74. 


SO  MEDICAL  EDUCATION 

and  Toronto,  insure  as  capable  and  homogeneous  an  enrolment  as  is  obtainable  at 
or  about  the  high  school  level.  A  few  others,  not  so  well  protected,  are  within  mea- 
surable distance  of  the  same  category, — the  medical  department  of  Tulane  Univer- 
sity and  Jefferson  Medical  College  (Philadelphia),  for  example.  In  general,  however, 
the  schools  of  this  division  are  difficult  to  classify;1  for  they  freely  admit  students 
on  bases  that  are  not  only  hopelessly  unequal  to  each  other,  but  are  even  incapable 
of  reduction  to  a  common  denominator.  On  their  actual  standards  the  catalogue 
statements  throw  little  light:  there  the  requirements  are  cast  in  the  form  of  a  de- 
scending scale,  running  from  the  top,  down.  Equally  acceptable  in  their  sight  are  a 
bachelor's  degree  from  a  college  or  a  university,  a  diploma  from  an  "accredited" 
high  school,  an  examination  in  a  few  specified  and  several  of  a  wide  range  of  op- 
tional studies,  and  a  certificate  from  the  principal  of  a  high  school,  normal  school, 
or  academy,  from  a  "reputable  instructor,"  from  a  state  or  city  superintendent  of 
education,  or  from  a  state  board  of  medical  examiners,  that  stamps  the  applicant 
as  possessing  the  "equivalent"  of  a  high  school  education.  Now  it  is  clear  that  the 
alternatives  at  the  top  are  mainly  decorative.  The  real  standard  is  perilously  close 
to  the  "equivalent"  that  creeps  in  modestly  at  the  bottom.  There  is,  of  course, 
no  active  prejudice  anywhere  against  Ph.D.'s  and  A.M.'s  and  A.B.'s  and  B.Sc.'s; 
they  are  apt  to  be  rather  conspicuously  exploited,  when  they  drift  in.  But  they  do 
not  set  the  pace;  they  do  not  determine  or  even  vitally  affect  the  character  of  the 
school.  In  these  instances  the  medical  curriculum  either  contains  the  pre-medical 
subjects  in  an  elementary  form,  or,  what  may  be  worse,  tries  to  go  ahead  entirely 
without  them.  The  real  standard  is  not  influenced  by  the  presence  of  degree  men, 
and  the  wonder  is  that  any  of  them  sacrifice  the  advantage  of  a  superior  education  by 
resorting  to  these  institutions.  The  minimum  is,  then,  the  real  standard;  all  else  is 
permissive;  for  to  the  needs  of  those  admitted  at  the  bottom  the  quantity  and  quality 
of  the  instruction  must  in  fairness  conform. 

To  get  at  the  real  admission  standard,  then,  of  these  medical  schools,  one  must 
make  straight  for  the  "equivalent."  On  the  methods  of  ascertaining  and  enforcing 
that,  the  issue  hangs.  Now  the  "equivalent"  may  be  defined  as  a  device  that  con- 
cedes the  necessity  of  a  standard  which  it  forthwith  proceeds  to  evade.  The  pro- 
fessed high  school  basis  is  variously  sacrificed  to  this  so-called  "equivalent."  The 
medical  schools  under  discussion  agree  to  accept  at  face  value  only  graduation  di- 
plomas2 from  "approved"  or  "accredited"  high  schools.  These  terms  have  a  definite 
meaning:  they  indicate  schools  which,  upon  proper  investigation,  have  been  recog- 
nized by  the  state  universities  of  their  respective  states,  or  by  some  other  competent 
educational  organization, — in  New  England,  by  the  College  Entrance  Certificate 
Board;  in  the  middle  west,  by  the  North  Central  Association.  High  schools  and  acad- 
emies not  acceptable  at  full  value  to  state  universities  or  to  the  bodies  just  named 

*In  Part  II  each  school  is  separately  characterized. 

2  As  a  matter  of  fact,  nongraduates  are  also  admitted  on  certificates — a  violation  of  standard,  of  course. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  31 

do  not  belong  to  the  "approved"  or  "accredited"  class:  their  diplomas  and  certifi- 
cates are  not,  therefore,  entitled  to  be  received  in  satisfaction  of  the  announced 
standard.  They  are  nevertheless  freely  accepted.  At  Tufts,  for  example,  the  first  year 
class  (1909-10)  numbers  151,  of  whom  only  little  more  than  half  submit  creden- 
tials that  actually  comply  with  the  standard;  of  the  others,  30  are  accepted  from 
non-accredited  schools  on  the  strength  of  diplomas  and  certificates  entitled  to  no 
weight  on  the  professed  standard  of  the  Tufts  Medical  School.1  This  is  a  common 
occurrence.  It  is  defended  on  the  ground  that  "  we  know  the  schools."  That  is,  how- 
ever, quite  impossible.  The  wisdom  of  Solomon  would  not  suffice  to  determine  the 
actual  value  of  credentials  so  heterogeneous  in  origin  and  content.  Universities  deal- 
ing with  far  less  various  material  organize  registration  and  inspection  bureaus  for 
their  protection  and  enlightenment.  But  not  infrequently  the  medical  departments 
of  these  very  institutions,  pretending  to  stand  on  the  same  basis  as  the  academic  de- 
partment, refrain  from  seeking  the  aid  of  the  university  registration  office.  The  me- 
dical department  of  Bowdoin  is  on  the  college  campus,  yet  its  authorities  accept  cer- 
tificates that  the  college  would  refuse;  the  medical  departments  of  Vanderbilt,  Tufts, 
George  Washington  University,  Creighton  (Omaha),  Northwestern,  the  Universities 
of  Vermont  and  Pennsylvania,2  are  in  easy  reach  of  intelligent  advice  which  they 
do  not  systematically  utilize.  In  striking  contrast,  the  medical  department  of  the 
University  of  Texas  at  Galveston  refers  all  credentials  to  the  registration  office  of 
the  university  at  Austin,  the  action  of  which  is  final. 

If  the  standard  were  enforced,  the  candidates  in  question,  not  offering  a  gradua- 
tion diploma  from  an  accredited  high  school,  would  be  compelled  to  enter  by  written 
examination.  But  the  examination  is,  as  things  stand,  only  another  method  of  eva- 
sion. Neither  in  extent  nor  in  difficulty  do  the  written  examinations,  in  the  rela- 
tively rare  cases  in  which  they  are  given,  even  approximate  the  high  school  stan- 
dard. Nor  are  they  meant  to  do  so.  Colleges  with  medical  departments  of  the  kind 
under  discussion  do  not  expect  academic  and  medical  students  to  pass  the  same  or 
the  same  kind  of  examination:  a  special  set  of  questions  is  prepared  for  the  medical 
candidates,  including  perhaps  half  the  subjects,  and  each  of  these  traversing  about  half 
the  ground  covered  by  the  academic  papers.  At  Tufts,  the  medical  matriculate  attempts 
six  papers,  representing,  all  told,  less  than  two  years  of  high  school  work ;  and  he  is 
accepted  on  condition  if  he  passes  three.3  Papers  of  similar  quality  are  put  forward  at 
Boston  University ;  those  at  Bowdoin  are  more  extensive  and  more  difficult,  though 
still  below  the  supposedly  equal  academic  standard.  The  written  examinations  held 
under  the  authority  of  the  state  boards  in  Kentucky,  Pennsylvania,  Missouri,*  are  of 

1  Those  still  remaining  are  commented  on  below. 

2  The  academic  authorities  here  pass  on  the  college  year. 

s  Of  the  class  above  mentioned  38  were  admitted  by  examination. 

4  A  St.  Louis  cramming  establishment,  conducted  by  the  wife  of  a  teacher  in  a  local  medical  school, 
offers  to  prepare  in  a  single  year,  according  to  the  Missouri  standard,  a  boy  who  has  never  had  any 


82  MEDICAL  EDUCATION 

the  same  insufficient  character.  In  Michigan  they  fairly  well  approximate  high  school 
value,  —  in  consequence  of  which  they  are  decidedly  unpopular.1  In  Illinois  the  writ- 
ten examination  has  been  transformed  into  an  informal  after-dinner  conversation 
between  candidate  and  examiner,  as  we  shall  presently  discover. 

There  remains  still  a  third  method  of  cutting  below  an  actual  high  school  stan- 
dard,— the  method  indeed  that  provides  much  the  most  capacious  loophole  for  the 
admission  of  unqualified  students  under  the  cloak  of  nominal  compliance  with  the 
high  school  standard.  The  agent  in  the  transactions  about  to  be  described  is  the 
medical  examiner,  appointed  in  some  places  by  voluntary  agreement  between 
the  schools,  elsewhere  delegated  by  the  state  board,2  or  by  the  superintendent  of 
public  instruction  acting  in  its  behalf,  for  the  purpose  of  dealing  with  students  who 
present  written  evidence  other  than  the  diploma  of  an  accredited  high  school.  It  is 
intended  and  expected  that  this  official  shall  enforce  a  high  school  standard.  In 
few  states  is  this  standard  achieved.  The  education  department  in  New  York,  the 
state  boards  in  Minnesota  and  Michigan,  maintain  what  may  be  fairly  called  a  scho- 
lastically  honest  high  school  requirement;  for  they  require  a  diploma  represent- 
ing an  organically  complete  secondary  school  education,  properly  guaranteed,  or,  in 
default  thereof,  a  written  examination  covering  about  the  same  ground :  there  is  no 
other  recourse. 

Elsewhere  the  state  board  is  legally  powerless,  as  in  Maryland,  or  unwilling  to  an- 
tagonize the  schools,  as  in  Illinois  and  Kentucky.  The  outside  examiners,  agreed  on 
by  the  schools  in  the  former  case,  designated  by  law  in  the  latter,  fall  far  short  of 
enforcing  a  high  school  standard.  The  examiner,  even  where  distinctly  well  inten- 
tioned,  as  in  Kentucky,  never  gets  sufficient  control.  The  schools  do  not  want  the 
rule  enforced,  and  the  boards  are  either  not  strong  enough  or  not  conscientious  enough 
to  withstand  them.  Besides,  the  examiners  lack  time,  machinery,  and  encouragement 
for  the  proper  performance  of  their  ostensible  office.  They  are  busy  men :  here,  a 
county  official;  there,  a  school  principal;  elsewhere,  a  high  school  professor.3  A  single 
individual,  after  his  regular  day's  work  is  over,  without  assistance  of  any  kind,  is 
thus  expected  to  perform  a  task  much  more  complicated  than  that  for  which  Harvard, 
Columbia,  and  the  University  of  Michigan  maintain  costly  establishments.  There  is 

high  school  training  at  all.  It  is  pointed  out  that  by  matriculating  at  once  the  student  may  escape 
any  subsequent  advance  in  entrance  requirements. 

1  In  Ohio  the  examinations  are  fairly  representative  of  high  school  values,  as  far  as  they  go.  But  up  to 
this  time  they  have  not  covered  a  complete  high  school  course  and  they  have  little  influence  on  enrol- 
ment, as  tutor-certificates  are  freely  accepted  in  their  stead. 

*In  these  cases,  the  requirement  is  really  a  practice,  not  an  educational  regulation.  But  the  effect  is 
the  same. 

•Occasionally  the  school  has  an  "arrangement"  by  which  defective  candidates  are  referred  to  a 
"coach,"  who  is  simultaneously  "examiner ;"  he  thus  approves  his  own  work.  This  is  the  practice  of 
the  George  Washington  University  medical  department.  Again,  the  school  refers  defective  candi- 
dates to  the  preparatory  department  of  its  own  university,  and  shortly  after  admits  them  on  an  as- 
surance of  the  "equivalent  from  that  source.  This  is  the  Creighton  school  (Omaha)  plan  ;  out  of  56 
members  of  its  first-year  class  (1908-9),  23  were  admitted  on  certificates  (not  diplomas)  of  this  kind. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  33 

no  set  time  when  candidates  must  appear.  They  drop  in  as  they  please,  separately: 
now,  before  the  medical  school  opens,  again,  long  after ;  sometimes  with  their  creden- 
tials, sometimes  without  them.  There  is  no  definite  procedure.  At  times,  the  examiner 
concludes  from  the  face  of  the  papers;  at  times  from  the  face  of  the  candidate.  The 
whole  business  is  transacted  in  a  free  and  easy  way.  In  Illinois,  for  example,  the  law 
speaks  of  "preliminary"  educational  requirements;  the  state  board  graciously  permits 
them  to  become  subsequents.  Students  enter  the  medical  schools,  embark  on  the  study 
of  medicine,  and  at  their  convenience  "square  up"1  with  one  of  the  examiners.  An 
evening  call  is  arranged ;  there  is  an  informal  talk,  aiming  to  elicit  what  "subjects" 
the  candidate  "has  had."  He  may,  after  an  interview  lasting  from  thirty  minutes  to 
two  hours,  and  rarely  including  any  writing,  be  "passed"  with  or  without  "condi- 
tions;" if  with  conditions,  the  rule  requires  him  to  reappear  for  a  second  "exam- 
ination" before  the  beginning  of  the  sophomore  year;  but  nothing  happens  if  he 
postpones  his  reappearance  until  a  short  time  before  graduation.2  Besides,  a  condi- 
tion in  one  subject  may  be  removed  by  "passing"  in  another!  "No  technical  ques- 
tions are  asked;  the  presumption  is  that  the  applicant  won't  remember  details." 
Formerly,  written  examinations  were  used  in  part ;  but  they  were  given  up  "  because 
almost  everybody  failed."  And  it  may  at  any  moment  happen  that  an  applicant  actu- 
ally turned  down  by  one  examiner  will  be  passed  by  another.  The  most  flagrantly 
commercial  of  the  Chicago  schools3  operate  "pre-medical"  classes,  where  a  hasty 
cram,  usually  at  night,  suffices  to  meet  the  academic  requirements  of  the  Illinois 
state  board:  "the  examiner's  no  prude,  he'll  give  a  man  a  chance,"  said  the  dean  of 
one  of  them. 

In  Pennsylvania  there  was  until  quite  lately  no  high  school  requirement  by  law; 
but  recent  legislation  fixes  the  high  school  or  its  equivalent,  on  which  the  better 
schools  had  previously  agreed,  as  the  legal  minimum.  Its  value  has  hitherto  varied. 
In  the  first  place,  the  examiners  have  accepted  three-year  high  school  graduates: 
"They  come  every  day  and  are  not  turned  down."  In  the  second  place,  the  alterna- 
tives in  the  matter  of  studies  are  so  many  that  he  must  indeed  have  had  narrow  op- 

1  Quotation  marks  indicate  throughout  words  taken  down  on  the  spot  in  the  course  of  interviews 
with  officials. 

2  New  York,  while  dealing  strictly  with  applicants  for  practice  who  have  been  educated  in  New  York 
state,  deals  somewhat  more  leniently  with  the  outsider.  The  New  York  law  provides  that  to  be  "re- 
gistered as  maintaining  a  proper  medical  standard,  "a  school  must,  among  other  things,  "require  that 
before  beginning  the  course  for  the  degree,  all  matriculates  afford  evidence  of  a  general  preliminary 
education  equivalent  to  at  least  a  four-year  high  school  course,"  etc.  (Handbook  9,  April,  1908,  p.  45.) 
As  a  matter  of  fact,  a  student  who  received  his  degree  from  a  school  on  the  accredited  or  registered 
list  (ibid.,  pp.  48-70)  may,  on  applying  for  registration  in  New  York,  find  his  preliminary  education 
to  have  been  below  the  New  York  standard.  In  certain  circumstances,  he  may  be  allowed  to  make 
good  his  defects,  provided  they  are  of  limited  scope.  He  is  thus  bringing  his  "preliminary  "  education 
up  to  standard,  after  he  has  received  his  M.D.  degree.  This  is  a  concession  that  the  New  York  Edu- 
cation Department  makes  to  the  loose  educational  administration  of  other  states.  It  is  to  be  hoped 
that  after  due  notice  given  it  may  be  discontinued.  The  offending  schools  may  very  properly  be  ex- 
cluded from  the  list. 

3  Bennett  Medical  College,  Illinois  Medical  College,  Jenner  Medical  College,  Chicago  Night  Univer- 
sity, Reliance  Medical  College. 


34  MEDICAL  EDUCATION 

portunities  who  cannot  piece  together  scraps  enough  to  gain  conditional  admission. 
"The  more  subjects,  the  more  points,"  one  dean  is  quoted  as  saying.  Partial  certifi- 
cates— a  year's  work  taken  here,  a  subject  or  part  of  a  subject  taken  there — may  be 
added  up  until  the  sum  equals  arithmetically  the  "units"  of  a  high  school  course. 
Moreover,  the  same  subject  can  be  counted  twice:  English  grammar  and  rhetoric  are 
two  subjects,  not  one;  so  are  English  literature  and  English  classics;  so  biology  and 
zoology.  Now,  aside  from  these  duplications,  it  is  absurd  to  sum  up  fragmentary  or 
isolated  "credits"  of  this  kind  as  "equivalent"  to  a  high  school  course,  even  if  the 
details  were  each  adequately  tested,  as  they  are  not.  For  a  school  curriculum  is  an 
organic  thing  in  whose  continuity  and  interrelations  its  educational  virtue  resides. 
One  subject  bears  upon  another;  one  year  reinforces  another.  A  curriculum  has,  as 
such,  unity,  purpose,  method.  It  is  not  merely  a  question  of  time,  still  less  of  de- 
tached specified  amounts  without  reference  to  time.1 

Things  are  not  essentially  different  in  Baltimore,  where  the  entire  matter  is  regu- 
lated by  voluntary  action  on  the  part  of  the  three  schools  belonging  to  the  division 
under  consideration.  The  "examination"  is  of  the  usual  kind:  "on  a  strict  account- 
ing they  would  all  fail."  In  Louisville,  students  are  admitted  into  the  local  school, 
the  medical  department  of  the  University  of  Louisville,  by  either  examination  or 
certificate.  The  examination  covers  less  than  a  four-year  high  school  course;  certifi- 
cates are  accepted  from  two-year  high  schools  as  full  satisfaction  of  the  requirements. 
Worse  still,  the  school  also  admits  students  without  either,  in  flat  disregard  of  its 
professed  standard  and  of  the  state  board.  St.  Louis,  Denver,  Nashville,  Pittsburgh, 
furnish  further  illustration.  In  none  of  these  does  the  examiner  exact,  whether 
through  examination  or  in  evaluation  of  certificates,  the  preliminary  standard  which 
he  is  ostensibly  appointed  to  enforce.  In  most  cases  the  very  word  "preliminary"  is 
a  misnomer,  just  as  we  have  found  it  to  be  in  Illinois.  For  example,  the  Ohio  re- 
quirement is  not  really  preliminary  to  medical  education.  The  schools  on  the  so-called 
high  school  or  equivalent  basis  admit  students  who  have  not  completely  satisfied  the 
examiner.  Strictly  speaking,  these  students  should  not  be  allowed  to  proceed  to  the 
sophomore  class;  for  their  medical  school  credits  beyond  the  first  year  cannot  count 
until  after  the  admission  requirements  have  been  satisfied.  Meanwhile  they  may 
have  reached  the  senior  class.  And  the  moment  they  satisfy  the  examiner  in  re- 
spect to  "preliminaries,"  now  "subsequents"  to  the  extent  of  two  or  three  years,  that 
moment  their  previous  work  in  the  medical  school  automatically  becomes  "good." 
At  Vanderbilt  the  first-year  class  had  been  studying  two  months, — yet  not  a  single 
"preliminary"  credential  had  been  even  submitted  to  the  examiner;  at  Louisville 

1  It  is  useless  to  review  all  the  states  separately,  for  the  differences  are  not  very  significant.  Ohio, 
however,  may  be  instanced  as  a  state  in  transit  towards  the  Michigan  standard.  At  present,  the  ex- 
aminer accepts  as  equivalent  to  graduation  from  an  approved  high  school  several  alternatives,  none 
of  which  is  really  equivalent:  (1)  whole  years  taken  in  different  institutions,  provided  they  sum  up 
four;  (2)  certificates  from  "known  instructors,"  testifying  that  candidates  have  "made  up"  condi- 
tions,— no  fixed  periods  of  study  being  required  in  such  cases;  (3)  examinations,  covering  hitherto 
less  than  the  high  school  course. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  35 

work  begins  November  15,  but  students  have  until  January  8  before  even  calling  on 
that  functionary.  Even  Michigan  wavers  here:  for  March  1, 1910,  had  come  around 
before  all  the  first-year  students  of  the  Detroit  School  of  Medicine  had  satisfied 
the  state  board.  In  such  cases  the  requirement  may  be  preliminary  to  graduation, 
or  to  practice,  or  to  what-not;  it  is  absurd  to  regard  it  as  preliminary  to  medical 
education.  For  the  whole  purpose  of  a  preliminary  is  to  guarantee  a  certain  degree 
of  training,  maturity,  and  knowledge  before  the  student  crosses  the  threshold  of  the 
medical  school,  on  the  ground  that  he  is  not  fit  to  cross  the  threshold  without  it; 
and  this  purpose  is  abandoned  if  he  is  allowed  to  enter  without  it  and  subsequently, 
by  hook  or  crook,  in  hastily  snatched  moments,  to  go  through  the  form  of  a  perfunc- 
tory compliance  that  becomes  complete  some  time  before  he  comes  up  for  his  M.D. 
degree.  There  is  no  retroactive  virtue  in  such  a  feat.  Educational  futility  can  go  no 
farther.  A  high  school  "preliminary  requirement,11  scrappily  accumulated  as  a  side 
issue  incidental  to  attendance  in  the  medical  school,  is  worse  than  nothing  to  the 
extent  that  it  has  interfered  with  undivided  attention  to  medical  study.1 

To  all  the  disorder  that  prevails  in  schools  of  this  grade  in  the  United  States, 
the  Canadian  schools  at  the  same  level  present,  with  two  exceptions,2  a  forcible 
contrast.  There,  too,  "equivalents"  are  accepted;  but  they  are  equivalents  in  fact 
as  in  name,  for  they  are  probed  by  a  series  of  written  examinations,  each  three 
hours  in  length,  held  at  a  stated  time  and  place,  only  and  actually  in  advance  of 
the  opening  of  the  medical  school,  entrance  to  which  is  absolutely  dependent  on 
their  outcome. 

The  quality  of  the  student  body  thus  accumulated  in  the  schools  under  discussion 
bears  out  the  above  description.  "The  facilities  are  better  than  the  students;"  "the 
boys  are  imbued  with  the  idea  of  being  doctors ;  they  want  to  cut  and  prescribe ;  all 
else  is  theoretical;"  students  accepted  in  chemistry  or  physics  "don't  know  a  baro- 
meter when  they  see  it ;"  "it  is  difficult  to  get  a  student  to  want  to  repeat  an  experi- 
ment (in  physiology).  They  have  neither  curiosity  nor  capacity."  "The  machinery 
does  n't  stop  the  unfit."  "  Men  get  in,  not  because  the  country  needs  the  doctors,  but 
because  the  schools  need  the  money.1"  "  What  is  your  honest  opinion  of  your  own 
enrolment?"  a  professor  in  a  Philadelphia  school  was  asked.  "Well,  the  most  I  would 
claim,"  he  answered,  "is  that  nobody  who  is  absolutely  worthless  gets  in"! 

1  Some  state  boards  are  already  in  possession  of  the  legal  right  to  enforce  a  preliminary  requirement. 
The  Illinois  law,  for  example,  says :  "The  State  Board  of  Health  shall  be  empowered  to  establish  a 
standard  of  preliminary  education  deemed  requisite  to  admission  to  a  medical  college  in  good  stand- 
ing" (par.  6  b,  ch.  91,  Kurd's  Revised  Statutes,  1908).  The  board  is  apparently  free  to  refuse  ex- 
amination to  any  applicant  whose  completed  entrance  certificate  does  not  bear  date  four  years 
prior  to  his  M.D.  diploma.  The  present  policy  of  the  Illinois  board  thus  squarely  contravenes  the 
obvious  intention  or  the  statute.  Contrast  with  this  lax  procedure  the  Scotch  requirement:  "The 
student  must  within  fifteen  days  of  the  commencement  of  study,  obtain  registration."  (Regulations 
for  the  Triple  Qualification,  ch.  i.  §  2.) 

8  Laval  University,  Montreal,  which  admits  students  below  grade ;  but  they  must  come  to  the  United 
States  to  practise,  for  they  have  no  standing  in  Canada ;  and  Western  University,  London,  Ont., 
which  leaves  the  entire  question  to  the  discretion  of  the  student,  who,  it  is  supposed,  will  conform 
to  the  local  requirement  of  the  place  in  which  he  expects  to  settle. 


86  MEDICAL  EDUCATION 

We  have  still  to  deal  with  schools  of  our  third  division.  They  are  most  numerous 
in  the  south,  but  they  exist  in  almost  all  medical  "centers," — San  Francisco,  Chicago, 
— there  plainly  on  the  sufferance  of  the  state  board,  for  the  law,  if  enforced,  would 
stamp  them  out, — St.  Louis  and  Baltimore.  Outside  the  south  they  usually  make 
some  pretense  of  requiring  the  "equivalent"  of  a  high  school  education;  but  no  ex- 
aminer of  any  kind  is  employed,  and  the  deans  are  extremely  reluctant  to  be  pinned 
down.  Southern  schools  of  this  division,  after  specifying  an  impressive  series  of  ac- 
ceptable credentials  ranging  once  more  from  university  degrees  downward,  announce 
their  satisfaction  with  a  "grammar  school  followed  by  two  years  of  a  high  school," 
or  in  default  thereof  a  general  assurance  of  adequate  "scholastic  attainments"  by  a 
state,  city,  or  county  superintendent,  or  some  other  person  connected  with  education 
or  purporting  to  be  such ;  but  the  lack  of  such  credentials  is  not  very  serious,  for 
the  student  is  admitted  without  them,  with  leave  to  procure  them  later.  Many  of 
the  schools  accept  students  from  the  grammar  schools.  Credentials,  if  presented,  are 
casually  regarded  and  then  usually  returned ;  a  few  may  be  found,  rolled  up  in  a 
rubber  band,  in  a  dusty  pigeonhole.  There  is  no  protection  against  fraud  or  forgery. 
At  the  College  of  Medicine  and  Surgery,  Chicago,  a  thorough  search  for  credentials 
or  some  record  of  them  was  made  by  the  secretary  and  several  members  of  the  fac- 
ulty, through  desk  drawers,  safe,  etc.,  but  without  avail.  The  school  is  nevertheless 
in  "good  standing  "  with  the  Illinois  state  board,  and  is  "accredited"  by  the  New  York 
Education  Department  to  the  extent  of  three  years'  work.  At  the  medical  department 
of  the  University  of  Georgia  I  was  told :  "  We  go  a  long  way  on  faith."  In  visits  to  med- 
ical colleges  certificates  were  found  from  non-existent  schools  as  well  as  from  non-exis- 
tent places.1  Of  course  a  few  fairly  competent  students  may  be  found  sprinkled  in  these 
institutions.  But  for  the  most  part,  the  student  body  gets  in  on  the  "equivalent." 
At  the  Atlanta  School  of  Medicine,  73  per  cent  of  last  year's  first-year  class  entered 
thus;  at  the  Mississippi  Medical  College  (Meridian,  Mississippi),  80  per  cent;  at  Bir- 
mingham Medical  College,  62  per  cent.  In  point  of  quality,  the  classes  are  not  com- 
petent to  use  such  opportunities  as  are  provided.  In  Atlanta  the  Grady  Hospital  is  open 
for  bedside  clinics  to  groups  of  six  students;  on  the  average,  two  come.  In  Chattanooga 
it  is  "rare  to  get  a  medical  student  who  knows  even  a  little  algebra;  it  is  impossible 
to  use  with  medical  students  the  text-books  in  science  used  in  freshman  academic 
classes."  At  Charlotte  I  was  told  that  "it  is  idle  to  talk  of  real  laboratory  work  for 

1  Accepted  certificates  are  in  this  form : 

To Dean : 

Sir :  I  have  examined  Mr ,  of ,  and  find  his  scholastic  attainments  equal 

to  those  requisite  for  a  first-grade  teacher's  certificate  in  our  public  schools,  with  the  equivalent  of  two  years 
of  high  school  study. 

Yours  very  truly. 

(Siffn  here) Superintendent  of  Public  Inttruction. 

These  are  furnished  to  the  student  by  the  medical  college  ;  he  needs  only  to  have  them  signed.  The 
college  does  not  investigate  the  signature ;  no  official  mark  or  seal  is  asked.  Even  the  medical  de- 
partment of  Vanderbilt  accepts  preliminary  certificates  in  this  form. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  37 

students  so  ignorant  and  clumsy.  Many  of  them,  gotten  through  advertising,  would 
make  better  farmers.  There's  no  use  in  having  apparatus  for  experimental  physio- 
logy— the  men  couldn't  use  it;  they're  all  thumbs." 

Statistical  proof  of  inadequacy  of  preparation  is  furnished  by  what  one  may  fairly 
call  the  abnormal  mortality  within  schools  operating  on  the  basis  of  "equivalents." 
The  standards  of  promotion  in  these  schools  watch  narrowly  the  action  of  the 
state  boards,  which  are  usually  lenient.  The  schools  are  too  weak  financially  to  do 
otherwise;  doubtful  points  are  resolved  in  the  boy's  favor.1  Hence  the  school  exam- 
inations play  less  havoc  than  would  follow  tests  strictly  constructed  in  the  public 
interest.  Yet  the  mortality  from  one  cause  or  another  by  the  close  of  the  first  year 
runs  from  20  to  50  per  cent.  At  the  Medico-Chirurgical  College  of  Philadelphia  an 
initial  first-year  enrolment  of  152  in  October  fell  to  1002  by  the  following  January 
first;  of  these,  60  passed  without  conditions,  much  less  than  one-half  the  original 
class  enrolment;  at  Tufts  the  entering  class  1908—9  shows  in  the  catalogue  an  enrol- 
ment of  141 ;  75  were  promoted,  with  or  without  conditions,  into  the  sophomore 
class;3  at  Cornell,  on  its  former  high  school  basis,  the  failures  at  the  close  of  the  first 
year  in  a  period  often  years  averaged  28  per  cent;  at  Buffalo,  the  failed  and  condi- 
tioned of  three  successive  first-year  classes  amounted  to  40  per  cent  of  the  total  en- 
rolment; at  Vanderbilt,  out  of  a  class  of  70,  the  dropped,  conditioned,  and  failed 
amounted  to  44  per  cent;  at  the  College  of  Physicians  and  Surgeons,  Atlanta,  70  per 
cent,  out  of  a  class  of  99.  In  schools  on  the  higher  basis,  i.e.,  two  years  of  college 
work  or  better,  the  instruction  is  more  elaborate,  the  work  more  difficult,  and  the 
examinations  harder;  for  scientific  ideals  rather  than  chances  with  the  state  board 
dominate.  Yet  the  mortality  drops  decisively.  At  the  Johns  Hopkins,  the  mortality 
during  three  successive  years  averages  less  than  5  per  cent,  only  half  of  which  is  due 
to  failure;  at  Ann  Arbor,  on  the  one-year  college  basis,  the  mortality  is  below  10  per 
cent.  The  exhibit  made  by  institutions  that  have  tried  both  standards  is  especially 
instructive.  At  the  University  of  Missouri,  during  the  last  three  years  of  the  high 
school  or  equivalent  basis,  there  was  a  mortality  due  to  actual  failure  of  35  per  cent; 
during  the  following  three  years,  when  one  year  of  college  work  was  required,  the 
mortality  fell  to  12£  percent.  At  the  medical  department  of  the  University  of  Minne- 
sota, during  the  last  three  years  of  the  high  school  requirement,  the  mortality  was 

1The  dean  of  one  school  admitted  that  he  carried  "men  easily  from  class  to  class,  but  plucked  them 
in  the  last  year," — an  excellent  thing  for  the  school :  it  collects  three  years'  fees  and  still  avoids  a  low 
record  in  the  state  board  examinations. 

2  Some  dropped  out  because  unable  to  qualify,  a  few  for  lack  of  funds,  others  because  of  inability  to 
do  the  work ;  but  the  enormous  number  that  drop  or  fail  throws  a  strong  light  on  the  miscellaneous 
character  of  the  enrolment  obtained  on  the  "equivalent"  basis. 

3  It  is  relatively  immaterial  to  our  argument  what  became  of  the  other  66 ;  they  represent  fatalities 
for  most  of  which  low  standards  are  to  blame.  As  a  matter  of  fact  they  are  thus  accounted  for :  14 
were  dropped  students  (not  catalogued  with  their  class  on  account  of  conditions);  20  failed  of  pro- 
motion ;  17  took  all  or  a  portion  of  first-year  examinations  1908-9,  but  did  not  return  1909-10 ;  15  left 
before  the  final  examinations. 


88  MEDICAL  EDUCATION 

18  per  cent;1  in  the  three  years  following,  on  the  basis  of  one  year  of  college  work, 
the  mortality  was  about  10  per  cent.  At  the  University  of  Virginia,  in  the  last  two 
years  on  the  old  basis,  38  per  cent  of  the  students  failed  in  one  or  more  subjects;  an 
increase  in  entrance  requirements  by  one  college  year  reduces  the  fatalities  to  14 
per  cent,  despite  the  augmented  difficulty  of  the  work.  The  medical  department  of 
the  University  of  Texas  has  gradually  advanced  from  a  two-year  high  school  basis 
to  a  four-year  high  school  basis;  on  the  lower  standard  there  were  34  per  cent  of 
hopeless  failures  in  1903,  as  against  13  per  cent  of  hopeless  failures  in  1908,  on  the 
higher.  The  requirement  of  a  college  year  assists  doubly, — first,  in  eliminating  the 
sham  equivalents;  next,  in  strengthening  the  equipment  of  those  who  actually  persist. 
Canada  accomplishes  the  former  by  means  of  the  examinations  already  noticed,  with 
the  result  that  the  mortality  there  is  distinctly  less  than  ours,  at  something  like  the 
same  ostensible  level.2 

The  breaches  made  by  the  fatalities  above  described  are  repaired  by  immigration, 
which  on  investigation  proves  to  be  in  most  instances  only  another  way  of  evading 
standards,  —  entrance  and  other.  To  some  extent,  good  students  who  find  themselves 
in  a  poor  school  endeavor  to  retrieve  their  error  by  transferring  themselves  to  a 
better ;  again,  there  is  a  certain  amount  of  enforced  emigration  annually  from  schools 
that,  like  the  University  of  Wisconsin,  offer  medical  instruction  in  the  first  two 
years  only.  In  the  main,  however,  the  "  lame  ducks"  move,  and,  strangely  enough, 
into  schools  that  are  at  the  moment  engaged  in  rejecting  a  number  equally  lame. 
The  interchange  is  veiled  by  pretended  examinations;  but  the  character  of  the 
examination  can  be  guessed  from  the  quality  of  the  students  that  pass  it.  Two 
standards  are  thus  often  broken  at  once :  An  ill  equipped  student  registers  in  a  low- 
grade  Chicago  school.  At  the  close  of  a  year  or  two,  he  transfers  to  the  College  of 
Physicians  and  Surgeons,  which  might  have  declined  him  originally.  He  has  thus  cir- 
cumvented its  admission  requirements.  If,  now,  he  has  previously  failed  in  the  medical 
coursessofarpursued,and  succeeds  "on  examination"  in  passing,  he  has  simultaneously 
circumvented  the  professional  requirements  as  well.  Instances  of  both  kinds  abound 
in  schools  at  and  below  the  high  school  basis.  In  1908-9  the  Medico-Chirurgical 
College  of  Philadelphia  accepted  failures  from  the  Jefferson  Medical  College  and 

1  This  relatively  low  mortality  is  to  be  ascribed  to  the  fact  that  the  student  body,  though  on  the  high 
school  basis,  contained  no  "equivalents." 

1 A  tabular  statement  will  perhaps  help  to  bring  these  facts  home.  Three  institutions  on  the  high  basis 
(Johns  Hopkins,  Harvard,  University  of  Minnesota)  show : 

Total  enrolment          Dropped  before  examinations          Failed  and  conditioned          Patted  without  condition! 
757  2  per  cent  17  per  cent  81  per  cent 

Seven  of  the  strongest  schools  in  the  United  States  on  the  high  school  or  equivalent  basis  (Jefferson 
Medical,  New  York  University,  University  of  Maryland,  Medieo-Chirurgical,  Tufts,  Yale,  and  Uni- 
versity of  Pennsylvania  (the  last  two  before  elevating  their  standard)  show : 

2390  11  per  cent  38  per  cent  £1  per  cent 

McGill  and  Toronto  show : 

945  5  per  cent  28  per  cent  67  per'cent 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  39 

the  University  of  Pennsylvania  and  advanced  them  to  the  classes  to  which  they  had 
been  denied  promotion  by  the  teachers  who  knew  them  best;  at  the  same  time 
the  Jefferson  Medical  College1  itself  accepted  and  in  the  same  way  advanced  failures 
from  New  York  University  and  the  University  of  Pennsylvania;  Tufts  admits  as 
"specials"  students  failed  at  Dartmouth,  Queen's  (Kingston,  Ontario),  and  the 
Medico-Chirurgical  of  Philadelphia;  the  medical  department  of  the  University  of 
Illinois  (College  of  Physicians  and  Surgeons,  Chicago)  fairly  abounds  in  rejected 
students  from  other  schools,  and  in  emigrated  students  from  the  low-grade  insti- 
tutions of  Chicago  and  elsewhere;  of  the  same  character  is  a  large  part  of  the  en- 
rolment of  the  medical  department  of  Valparaiso  University.  Failures  from  Ann 
Arbor  are  regarded  as  worthy  of  advancement  by  Northwestern  (Chicago).  The  Physi- 
cians and  Surgeons  of  Baltimore  gives  time  and  subject  credit — after  "examination," 
of  course — to  failures  turned  out  of  the  University  of  Buffalo,  New  York  University, 
the  University  of  Pennsylvania,  the  Jefferson  Medical  College,  and  Yale;  the  Uni- 
versity of  Maryland  is  equally  indiscriminate,  advancing  to  the  classes  which  they 
had  failed  to  reach  students  from  most  of  the  same  institutions  and  some  from  the 
local  College  of  Physicians  and  Surgeons  and  the  Baltimore  Medical  College,  besides. 
Other  Jefferson  Medical  failures,  not  to  be  found  in  the  two  Baltimore  schools  just 
named,  should  be  looked  for  in  the  Baltimore  Medical  College,  together  with  failures 
from  Tufts,  Long  Island  Hospital  Medical  College,  etc.  The  upper  classes  of  two 
Baltimore  schools — the  Maryland  Medical  College  and  the  Atlantic  Medical  Col- 
lege— are  largely  recruited  by  emigration  from  other  schools;2  the  latter  of  these  had 
(1908-9)  a  senior  class  of  31,  a  freshman  class  of  1, — and  every  member  of  the  senior 
class  had  been  admitted  to  advanced  standing  from  some  other  school.3 

Is  this  the  best  that  can  be  done?  Will  the  actual  enforcement  of  a  real  and  ade- 
quate standard  starve  any  section  of  the  country  in  the  matter  of  physicians? 

The  question  can  be  answered  without  guesswork  or  speculation.  The  south  re- 
quires something  like  400  doctors  annually.4  How  high  a  standard  can  it  enforce,  and 
still  get  them?  In  the  year  1908—9  there  were  15,791  male  students  in  four-year  high 
schools  in  six  southern  states,6  — Alabama,  Georgia,  Louisiana,  South  Carolina,  Vir- 

1  This  institution,  like  others,  admits  to  advanced  standing  a  considerable  number  of  students  from 
schools  whose  entrance  requirements  are  much  below  its  own ;  e.g.,  in  the  session  above  referred  to, 
there  were  several  students  from  the  medical  department  of  Fort  Worth  University,  whose  entrance 
requirement  is  nominal ;  from  the  University  or  Oregon,  College  of  Physicians  and  Surgeons,  San 
Francisco,  Keokuk,  Denver  and  Gross.  At  the  same  time,  it  deals  severely  with  its  own  student 
body,  for  it  refuses  promotion  annually  to  a  large  number,  who  emigrate  chiefly  to  Baltimore. 

2  Mississippi  Medical  College,  Meridian,  was  similarly  recruited. 

3  Among  other  schools  guilty  of  advancing  students  to  whom  promotion  had  been  refused  by  their 
own  schools  may  be  mentioned :  College  of  Physicians  and  Surgeons,  Atlanta,  Georgetown  Univer- 
sity (Washington,  D.  CA  Denver  and  Gross,  University  of  Colorado,  George  Washington  Univer- 
sity, Milwaukee  Medical  College. 

4  The  former  secretary  of  the  Southern  Medical  College  Association  calculated  that  300  would  suffice. 

5  For  these  figures  we  are  indebted  to  a  painstaking  census  conducted  by  the  secondary  school  in- 
spectors maintained  in  these  states  by  the  General  Education  Board. 


40  MEDICAL  EDUCATION 

ginia  and  Texas;  there  were  in  the  previous  year  5877  male  students  in  the  academic 
departments  of  the  southern  state  universities,  and  1653  more  in  endowed  institu- 
tions of  similar  grade;1  a  population  of  over  23,0002  bordering  on  high  school  gradua- 
tion and  widely  distributed  over  the  entire  area.  Our  question  is  thus  already  an- 
swered. The  best  material  for  the  making  of  a  few  hundred  southern  doctors  annually 
does  not  have  to  be  torn  from  the  plough. 

But  these  figures  convey  by  no  means  the  whole  truth.  The  south  is  in  the  midst 
of  a  genuine  educational  renaissance.  Within  the  last  few  years  every  southern  state 
under  the  leadership  of  the  state  university,  the  state  department  of  education,  and 
certain  endowed  institutions  like  Vanderbilt  University,  has  set  enthusiastically  to 
work  to  develop  its  common  and  secondary  school  systems  after  the  admirable  model 
furnished  by  the  robust  communities  of  the  middle  west.  The  professors  of  secondary 
education  in  the  state  universities  are  the  evangelists  of  this  auspicious  movement. 
Young,  intelligent,  well  trained,  these  sturdy  leaders  ceaselessly  traverse  the  length 
and  breadth  of  their  respective  states,  stimulating,  suggesting,  guiding,  organizing. 
It  is  an  inspiring  spectacle.  Three  years  ago  the  high  school  had  no  legal  standing 
in  Virginia;  to-day  the  state  is  dotted  with  two-year,  three-year,  and  four-year  high 
schools,  created  by  local  taxation,  with  a  considerable  subvention  from  the  state 
treasury.  There  are  already  2511  boys  in  fairly  well  equipped  four-year  high  schools, 
and  as  many  more  in  private  institutions  of  equal  value;  and  the  two-year  and  three- 
year  schools  are  growing  rapidly  into  fuller  high  school  stature.  It  needs  no  argument 
to  prove  that  Virginia  can  at  once  procure  its  doctors  from  among  the  bvna-jide  gra- 
duates of  such  high  schools  and  better.  What  is  true  of  Virginia  is  tine  of  every  other 
southern  state.  In  Alabama,  for  example,  three  years  ago  there  was  scarcely  a  pub- 
lic high  school  in  the  state ;  to-day  there  are  61  public  four-year  high  schools,3 1 1  pri- 
vate four-year  high  schools,  and  15  town  and  city  three-year  high  schools.  Of  the 
345  teachers  employed  in  these  schools,  184  are  college  graduates  and  55  more  have 
had  at  least  two  years  of  college  work.  Of  course  the  situation  is  uneven;  it  lacks 
homogeneity.  Standards  are  more  or  less  confused;  distinctions  are  not  everywhere 
clear.  The  schools  have  frequently  shot  up  like  ungainly  boys,  who  first  get  their 
height  and  fill  up  afterwards;  their  four  years  are  not  yet  the  four  years  of  Boston 
or  Indianapolis.  But  this  is  a  phenomenon  of  hopeful  omen ;  it  provides  the  frame- 
work for  a  vigorous  and  imminent  maturity.  The  universitiesand  the  professional  schools 
have  in  this  emergency  a  clear  duty :  to  call  things  by  their  right  names,  to  abandon 
the  apologetic  attitude,  to  cease  from  compromises  which  tempt  the  student  from  the 
high  school  and  then  set  up  the  successful  temptation  as  a  sufficient  excuse  for  their 

1  Compiled  from  the  Report  of  the  United  States  Commissioner  of  Education,  1908. 

*  Not  including  four-year  high  schools  of  Mississippi,  Florida,  North  Carolina,  Tennessee,  Arkansas, 
and  Kentucky,  which  would  considerably  increase  these  figures.  They  are  omitted  because  equally 
reliable  data  are  not  at  hand. 

*  Under  legislative  enactment  approved  August  7,  1907,  the  state  contributes  $2000  a  year  to  aid  any 
county  that  establishes  its  own  nigh  school 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  41 

own  folly  in  so  doing.  Let  them  reinforce  the  high  school  by  the  opposite  policy; 
they  will  soon  perceive  the  needlessness  of  the  exceptions  which  they  still  suggest, 
and  often  even  require.  How  much  longer  will  the  southern  people,  generously  spend- 
ing themselves  in  the  effort  to  create  high  school  systems,  continue  to  handicap  their 
development  by  allowing  medical  education  legally  to  rest  on  an  ante-bellum  ba^s? 

The  duty  of  the  southern  universities  at  this  juncture  is  clear.  They  are  equally 
bound  to  assist  the  development  of  the  secondary  school  and  to  furnish  the  southern 
people  an  improved  type  of  physician.  They  do  both  if,  while  actually  enforcing  the 
standard  above  advocated,  they  provide  the  best  medical  training  obtainable  at  that 
level.  As  a  matter  of  fact,  a  highly  useful  doctor  can  be  trained  on  the  high  school 
basis  if  his  defects,  frankly  admitted,  are  made  the  occasion  for  more,  instead  of  less, 
efficient  instruction.  The  weak  southern  schools  apologize  for  their  wretchedness  by 
alleging  the  shortcomings  of  the  student  body.  But  the  shortcomings  of  the  students 
are  a  call  for  better,  rather  than  an  excuse  for  worse,  teaching.  On  the  whole,  a  south- 
ern university  will  for  a  time  probably  do  best  to  put  its  strength  unreservedly 
into  the  improved  instruction  of  a  larger  body  of  students  at  the  high  school  level, 
rather  than  to  train  a  smaller  body  on  a  somewhat  higher  basis.  What  with  the  other 
influences  working  to  discredit  the  proprietary  medical  school,  if  Tulane,  Vanderbilt, 
and  Texas  furnish  actual  high  school  graduates  with  an  education  as  good  as  that 
of  Toronto  or  of  McGill,  they  will  soon  get  control  of  the  field,  they  will  educate 
the  southern  public  to  look  to  them  for  their  physicians,  and  they  will  induce  the 
state  legislatures  to  support  a  position  undeniably  reasonable,  so  that  when  they  at 
last  make  the  upward  move,  there  will  be  no  low-grade  medical  schools  to  profit  by 
the  step  and  to  make  it  a  pretext  for  the  continuance  of  commercialism  in  medical 
education.1  » 

The  state  of  Texas  has  taken  a  sound  and  yet  conservative  position.  Beginning 
with  1909,  it  has  decreed  a  gradual  annual  rise  of  standard  that  will  shortly  re- 
sult in  making  its  four-year  high  school  the  legal  basis  of  medical  education.  Cau- 
tious elevation  thus  avoids  all  danger  of  breaking  with  the  state  school  system.  The 
statute  is  not  free  from  defects,  for  it  provides  for  the  acceptance,  at  their  face  value, 
of  the  medical  student  certificates  of  reciprocating  states;  but  the  Texas  state  board, 
having  dealt  vigorously  with  the  worst  of  the  Texas  schools,  will  in  all  probability 
make  effective  use  of  the  power  in  its  hands.  Other  southern  states  must  inevitably 
follow.  It  is  of  course  important  that  they  should  not  move  faster  than  their  edu- 
cational facilities;  but  it  is  equally  important  that  they  should  not  move  any  more 
slowly.  Thus  far,  Texas  alone  has  made  an  effort  to  keep  pace. 

The  situation  is  even  clearer,  in  so  far  as  it  touches  the  rest  of  the  country.  We 
estimate2  that  outside  the  south  1500  doctors  annually  graduated  will  provide  for 

1  For  more  detailed  consideration  on  this  point,  the  reader  is  referred  to  the  discussions  in  Part  II  of 
the  various  southern  states. 

2  In  chapter  a. 


42  MEDICAL  EDUCATION 

all  the  real  and  many  imaginary  needs.  There  are  at  this  date  something  like  8000 
public  and  over  1000  private  high  schools,  so  widely  dispersed  over  the  area  under 
consideration  that  on  the  average  few  boys  need  go  over  five  miles  to  school.1  In 
the  public  high  schools  alone  there  are  enrolled  300,000  boys.8  What  excuse  exists 
for  cutting  under  the  high  school?  We  can  indeed  do  better  than  to  accept  as  the 
basis  of  a  medical  education  the  high  school  "flat."  In  the  colleges,  universities,  and 
technical  schools  of  the  north  and  west,  exclusive  of  preparatory  and  professional 
departments,  there  were  in  1908,  120,000s  male  students.  The  number  swells  with 
unprecedented  rapidity ;  long  before  the  country  has  digested  the  number  of  doctors 
now  struggling  for  a  livelihood,  it  will  have  doubled.  Already  in  1907,  903  of  the 
doctors  graduated  in  that  year  held  academic  degrees;  that  is  to  say,  fully  one-half 
of  the  number  the  country  actually  needed  could  conform  to  the  standard  that  has 
been  urged,  or  better.  There  is  at  this  moment  absolutely  nothing  in  the  educational 
situation  outside  the  south  that  countenances  the  least  departure  from  the  scientific 
basis  necessary  to  the  successful  pursuit  of  modern  medicine. 

For  whose  sake  is  it  permitted?  Not  really  for  the  remote  mountain  districts  of 
the  south,  for  example,  whence  the  "yarb  doctor,""  unschooled  and  unlicensed,  can  in 
no  event  be  dislodged;  nor  yet  for  that  twilight  zone,  on  the  hither  edge  of  which 
so  many  low-grade  doctors  huddle  that  there  is  no  decent  living  for  those  already 
there  and  no  tempting  prospect  for  anybody  better:  ostensibly,  "for  the  poor  boy." 
For  his  sake,  the  terms  of  entrance  upon  a  medical  career  must  be  kept  low  and  easy. 
We  have  no  right,  it  is  urged,  to  set  up  standards  which  will  close  the  profession  to 
"poor  boys." 

What  are  the  merits  of  this  contention  ?  The  medical  profession  is  a  social  organ, 
created  not  for  the  purpose  of  gratifying  the  inclinations  or  preferences  of  certain 
individuals,  but  as  a  means  of  promoting  health,  physical  vigor,  happiness — and 
the  economic  independence  and  efficiency  immediately  connected  with  these  factors. 
Whether  most  men  support  themselves  or  become  charges  on  the  community  depends 
on  their  keeping  well,  or  if  ill,  promptly  getting  welL  Now,  can  anyone  seriously 
contend  that  in  the  midst  of  abundant  educational  resources,  a  congenial  or  profit- 
able career  in  medicine  is  to  be  made  for  an  individual  regardless  of  his  capacity 
to  satisfy  the  purpose  for  which  the  profession  exists?  It  is  right  to  sympathize  with 
those  who  lack  only  opportunity;  still  better  to  assist  them  in  surmounting  obsta- 
cles; but  not  at  the  price  of  certain  injury  to  the  common  weal.  Commiseration  for 
the  hand-spinner  was  not  suffered  for  one  moment  to  defeat  the  general  economic 
advantage  procurable  through  machine-made  cloth.  Yet  the  hand-spinner  had  a  sort 
of  vested  right:  society  had  tacitly  induced  him  to  enter  the  trade;  he  had  grown 
up  in  it  on  that  assurance;  and  he  was  now  good  for  nothing  else.  Your  "poor  boy" 

1  Wilgus,  Legal  Education  in  the  United  States,  p.  29. 

1  There  are  33,000  more  in  the  preparatory  departments  of  colleges  and  universities. 

•We  are  indebted  for  these  statistics  to  the  United  States  Commissioner  of  Education. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  43 

has  no  right,  natural,  indefeasible,  or  acquired,  to  enter  upon  the  practice  of  medi- 
cine unless  it  is  best  for  society  that  he  should. 

As  a  matter  of  fact,  the  attainments  required  by  our  entire  argument  are  not,  as 
a  rule,  beyond  the  reach  of  the  earnest  poor  boy.  He  need  only  take  thought  in  good 
season,  lay  his  plans,  be  prudent,  and  stick  to  his  purpose.  Without  these  qualities, 
medicine  is  no  calling  for  him ;  with  them,  poverty  will  rarely  block  his  way.  Besides, 
if  poverty  is  to  be  a  factor  in  determining  entrance  standards,  just  where  does  pov- 
erty cease  to  excuse  ignorance?  Apparently  the  inexcusable  degree  of  ignorance  be- 
gins just  where  the  ability  to  pay  fees  leaves  off.  For  the  schools  that  maintain 
"equivalents'1  for  the  sake  of  the  "poor  boy"  are  not  cheap,  and  the  student  who 
can  pay  his  expenses  in  them  can  also  pay  for  something  better,  and  pay  his  fees  the 
student  must;  for  it  is  precisely  the  proprietary  and  independent  schools,  avowedly 
solicitous  for  the  "poor  boy,"  that  do  the  least  for  him  by  way  of  scholarship  or  other 
exemption.1  They  exact  a  complete  settlement  in  cash  or  notes.  Thus  a  four-year 
medical  education  in  Baltimore,  Philadelphia,  or  Chicago  schools,  on  the  "equiva- 
lent" basis,  costs  a  boy  in  tuition  fees  and  board  about  $1420.  The  same  student  can 
go  to  Ann  Arbor,  get  there  two  years  of  college  work  in  the  pre-medical  sciences  and 
modern  languages,  and  four  years  in  medicine,  besides,  for  an  expenditure  of  SI 466, 
covering  the  same  items.  Thus  six  years  at  Ann  Arbor  are  not  appreciably  more  ex- 
pensive than  four  years  in  Baltimore,  Philadelphia,  or  Chicago.  Or,  if  a  large  city  be 
preferred,  he  can  get  his  two  years  in  the  admirable  pre-medical  laboratories  of  the 
University  of  Minnesota,  at  Minneapolis,  followed  by  his  four-year  medical  work 
there,  for  very  little  more.  Low  entrance  requirements  flourish,  then,  for  the  benefit  of 
the  poor  school,  not  of  the  poor  boy.  Meanwhile,  opportunities  exist,  in  a  measure 
during  the  school  year,  still  more  during  vacation,  to  earn  part,  perhaps  all,  of  the 
required  sum.2  Doubtless  in  the  near  future,  the  problem  will  be  still  further  simpli- 
fied in  the  interest  of  the  better  training  by  increased  scholarship  and  other  endow- 
ments, as  in  Germany.  Meanwhile,  it  is  dubious  educational  philanthropy  to  interrupt 
a  poor  boy's  struggle  upwards  by  inviting  him  into  a  medical  school  where  there  are 
excessively  large  chances  of  failure,  escaping  which  he  is  at  once  exposed  to  a  disad- 
vantageous competition  with  men  better  trained  by  far. 

So  much  from  the  standpoint  of  the  individual.  The  proper  method  of  calculating 
cost  is,  however,  social.  Society  defrays  the  expense  of  training  and  maintaining  the 
medical  corps.  In  the  long  run  which  imposes  the  greater  burden  on  the  community, — 

1  Three  scholarships,  amounting  to  tuition  fees  for  one  year,  are,  however,  annually  awarded  at  the 
University  of  Maryland. 

2  It  is  stated  that  at  the  University  of  Chicago  "the  opportunities  for  taking  work  are  more  numer- 
ous than  the  number  of  students  desiring  to  take  advantage  of  them. .  . .  There  is  ample  opportunity 
for  the  energetic  student  to  earn  his  way,  either  in  whole  or  in  part,  and  opportunities  usually  out- 
number those  seeking  them. "  School  Review,  January,  1910  (Notes  and  News).  It  must,  of  course,  be 
remembered  that  only  the  vigorous  and  talented  can  afford  to  undertake  the  study  of  medicine  under 
such  conditions.  The  others  are  barred  just  as  effectively  from  the  low-grade  as  from  the  high-grade 
school.  Students  are  found  "working  their  way  through"  at  the  medical  departments  of  Harvard, 
Michigan,  Toronto,  McGill,  etc. 


44  MEDICAL  EDUCATION 

the  training  of  a  needlessly  vast  body  of  inferior  men,  a  large  proportion  of  whom  break 
down,  or  that  of  a  smaller  body  of  competent  men  who  actually  achieve  their  purpose? 
When  to  the  direct  waste  here  in  question  there  is  added  the  indirect  loss  due  to  in- 
competency,  it  is  clear  that  the  more  expensive  type  is  decidedly  the  cheaper.  Aside 
from  interest  on  investment,  from  loss  by  withdrawal  of  the  student  body  from  produc- 
tive occupations,  the  cost  of  our  present  system  of  medical  education  is  annually  about 
83,000,000,  as  paid  in  tuition  fees  alone.  The  number  of  high-grade  physicians  really 
required  could  be  educated  for  much  less;  the  others  would  be  profitably  employed 
elsewhere;  and  society  would  be  still  further  enriched  by  efficient  medical  service. 

The  argument  is  apt  to  shift  at  this  point.  If  we  refuse  to  be  moved  by  the  "poor 
boy,"  pity  the  small  towns;  for  it  is  speciously  argued  that  the  well  trained,  college- 
bred  student  will  scorn  them.  Not  sympathy  for  the  poor  boy  requires  us  now  to 
sacrifice  the  small  town  to  him,  but  sympathy  for  the  small  town  requires  us  to  sac- 
rifice the  poor  boy  to  it.  Two  vital  considerations  are  overlooked  in  this  plea.  In  the 
first  place,  the  small  town  needs  the  best  and  not  the  worst  doctor  procurable.  For 
*  the  country  doctor  has  only  himself  to  rely  on :  he  cannot  in  every  pinch  hail  spe- 
cialist, expert,  and  nurse.  On  his  own  skill,  knowledge,  resourcefulness,  the  welfare 
of  his  patient  altogether  depends.  The  rural  district  is  therefore  entitled  to  the  best 
trained  physician  that  can  be  induced  to  go  there.  But,  we  are  told,  the  well  trained 
man  will  not  go;  he  will  not  pay  for  a  high-grade  medical  education  and  then  con- 
tent himself  with  a  modest  return  on  his  investment.  Now  the  six-year  medical  edu- 
cation (that  based  on  two  college  years)  and  the  four-year  medical  education  (that 
based  on  the  high  school  or  equivalent)  may,  as  we  saw  above,  be  made  to  cost  the 
same  sum.  As  far  as  cost  is  concerned,  then,  the  better  sort  of  four-year  medical  edu- 
cation mifct  have  precisely  the  same  effect  on  distribution  of  doctors  as  the  six-year 
training  furnished  by  the  state  universities.  If  a  Jefferson  graduate  is  not  deterred 
by  the  cost  of  his  education  from  seeking  a  livelihood  in  the  country,  the  Ann  Arbor 
or  Minnesota  man  will  not  be  deterred,  either.  But  a  deeper  question  may  be  raised. 
What  is  the  financial  inducement  that  persuades  men  scientifically  inclined  to  do 
what  they  really  like  ? — for  a  man  who  does  not  like  medicine  has  no  business  in  it. 
How  far  does  the  investment  point  of  view  actually  control?  Complete  and  reliable 
data  are  at  hand.  The  college  professor  has  procured  for  himself  an  even  more  elaborate 
and  expensive  training  than  has  here  been  advocated  for  the  prospective  physician. 
Did  he  require  the  assurance  of  large  dividends  on  his  investment?  "The  full  professor 
in  the  one  hundred  institutions  in  the  United  States  and  Canada  which  are  financially 
strongest  receives  on  the  average  an  annual  compensation  of  approximately  $2500."  * 
But  the  scholar  does  not  usually  advance  beyond  the  assistant  professorship :  what  fig- 
ure has  financial  reward  cut  with  him  ?  "At  the  age  of  twenty-six  or  twenty-seven,  after 
seven  years  of  collegiate  and  graduate  study,  involving  not  only  considerable  outlay, 

1 "  The  Financial  Status  of  the  Professor  in  America  and  in  Germany."  Carntgit  Foundation  for  th« 
Adtanrement  of  Teaching,  Bulletin  II.,  p.  vi. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  45 

but  also  the  important  item  of  the  foregoing  of  earning  during  this  period,  he  is  the 
proud  possessor  of  his  Ph.  D.  and  is  ready  to  enter  his  profession.  The  next  five  years 
he  spends  as  instructor.  In  his  thirty-second  year  he  reaches  assistant  professorship. 
He  is  now  in  his  thirty-seventh  year,  having  been  an  assistant  professor  for  five  years. 
His  average  salary  for  the  ten  years  has  been  $1325.  ...  At  thirty-seven  he  is  mar- 
ried, has  one  child,  and  a  salary  of  $1800."  *  In  Germany  "the  road  to  a  professor- 
ship involves  a  period  of  training  and  of  self-denial  far  longer  and  more  exacting 
than  that  to  which  the  American  professor  submits;"3  in  France  "there  are  no  pe- 
cuniary prizes  whatever  in  their  calling  for  even  those  who  attain  its  highest  posts."3 
What  is  even  more  to  the  point, — the  posts  of  instructor  and  assistant  in  small  col- 
leges situated  in  out-of-the-way  places  can  be  readily  filled  at  slender  salaries  with 
expensively  trained  men.  Of  course  there  are  compensations.  But  the  point  is  that  a 
large  financial  inducement  is  not  indispensable,  provided  a  man  is  doing  what  he 
likes.  In  most  sections  the  country  doctor  has  better  worldly  prospects.  The  fact 
stands  out  that  it  is  not  income  but  taste  that  primarily  attracts  men  into  scholarly 
or  professional  life.  That  granted,  the  prospect  of  a  modest  income  does  not  effectually 
deter ;  and  not  infrequently  the  charm  of  living  away  from  large  cities  may  even 
attract. 

Our  limited  experience  with  physicians  trained  at  a  high  level  sustains  this  view. 
We  have  thus  far  produced  relatively  few  college-bred  physicians;  large  cities  have 
bid  high  for  them,  without,  however,  bagging  all.  Johns  Hopkins  graduates  in  med- 
icine, to  take  the  highest  quality  the  country  has  produced,  are  already  scattered 
through  thirty-two  states  and  territories.  As  if  to  prove  that  money  is  not  the  sole 
deciding  consideration^  dozen  have  gone  as  missionaries  to  the  Orient  and  several  into 
the  army  and  navy.  In  this  country  there  is  a  Johns  Hopkins  man  practising  at  Clay- 
ton, Alabama,  with  1000  inhabitants;  at  Fort  Egbert,  Alaska,  with  458;  at  Gorham, 
Colorado,  with  364;  at  Chattahoochee,  Florida,  with  460;  at  Fort  Bayard,  New  Mex- 
ico, with  724;  at  Sonyea,  New  York,  with  300;  at  Blue  Ridge  Summit,  Pennsylvania, 
with  50;  at  Wells  River,  Vermont,  with  660;  at  Fairfax,  Virginia,  with  200;  at  Fort 
Casey,  Washington,  with  300;  at  Kimball,  West  Virginia,  with  2000;  at  Mazomanie, 
Wisconsin,  with  900.  They  have  scattered  to  the  four  winds,  and  inevitably.4  No 
single  influence  controls :  home,  money,  taste,  opportunity,  all  figure.  When  we  have 
produced  as  large  a  number  of  well  trained  doctors  as  Germany,  they  will  be  found 
in  our  villages,  just  as  one  finds  them  over  there.  Minnesota,  closed  after  1912  to  all 
low-grade  graduates,  Kansas  and  North  and  South  Dakota,  agricultural  states,  Con- 

1  Statistics  from  twenty  leading  universities,  discussed  by  Guido  H.  Marx  in  address.  The  Problem  of 
the  Assistant  Professor,  before  Association  of  American  Universities,  January,  1910. 

2  Carnegie  Foundation,  Bulletin  II.,  p.  vii. 

3  Bodley :  France,  voL  i.  p.  54. 

4  Western  Reserve  men  (three  years  of  college  required  for  entrance)  are  to  be  found  in  Cochranton, 
Pennsylvania  (population,  724);  Solon  Springs,  Wisconsin  (population,  400);  Kinsman,  Ohio  (popula- 
tion, 824) ;  Rawson,  Ohio  (population,  552). 


46  MEDICAL  EDUCATION 

necticut,  Indiana,  Colorado,  look  forward  confidently  to  the  high  standard  basis.  Is 
there  any  reason  founded  in  consideration  for  public  welfare  which  holds  back  Illinois, 
New  York,  Pennsylvania,  from  similar  action? 

There  is,  however,  still  another  standpoint  from  which  the  question  under  discus- 
sion ought  to  be  viewed.  We  have  been  endeavoring  to  combat  the  argument  in 
favor  of  admittedly  inferior  schools  dependent  on  fees  on  the  ground  that  in  the 
east,  north,  and  west,  these  schools  have  already  outlived  their  usefulness;  that,  even 
in  the  south,  the  need,  greatly  exaggerated,  will  gradually  disappear.  Let  us,  how- 
ever, for  the  moment  concede  that  the  south,  and  perhaps  other  parts  of  the  country, 
still  require  some  medical  schools  operating  on  the  high  school  basis,  or  a  little  less. 
Does  it  follow  that  the  proprietary  or  independent  unendowed  medical  school  has 
thereby  established  its  place?  By  no  means.  It  is  precisely  the  inferior  medical  stu- 
dent who  requires  the  superior  medical  school.  His  responsibilities  are  going  to  be 
as  heavy  as  those  of  his  better  trained  fellow  practitioner  :  to  be  equally  trustworthy, 
his  instruction  must  be  better,  not  worse.  The  less  he  brings  to  the  school,  the  more 
the  school  must  do  for  him.  The  necessity  of  recruiting  the  medical  school  with  high 
school  boys  is  therefore  the  final  argument  in  favor  of  fewer  schools,  with  better 
equipment,  conducted  by  skilful  professional  teachers. 

The  truth  is  that  existing  conditions  are  defended  only  by  way  of  keeping  un- 
necessary medical  schools  alive.  The  change  to  a  higher  standard  could  be  fatal  to 
many  of  them  without  in  the  least  threatening  social  needs.  Momentarily  there  would 
be  a  sharp  shrinkage.  But  forethought  would  be  thus  effectively  stimulated;  trained 
men  would  be  attracted  into  the  field;  readjustment  would  be  complete  long  before 
any  community  felt  the  pinch.1  Despite  prevailing  confusion — legal,  popular,  and 
educational — as  to  what  good  training  in  medicine  demands,  the  enrolment  in  the 
five  schools  which  have  during  the  last  four  years  required  two  or  more  years  of  college 
work  is  already  1186  students,  and  is  increasing  rapidly.2  When  the  Johns  Hopkins 
plans  were  under  discussion  in  the  middle  seventies,  Dr.  John  S.  Billings,  the  adviser 
of  the  trustees  in  things  medical,  suggested  that  the  graduating  class  be  limited  to 
twenty-five.  "  I  think  it  will  be  many  years  before  the  number  of  twenty-five  for 
the  graduating  class  can  be  reached,"  he  said.8  The  school  opened  in  1893;  the  first 
class,  graduated  in  1897,  numbered  15;  the  third,  graduated  in  1899,  numbered  32:  so 
promptly  did  the  country  respond.  Institutions  that  have  switched  from  the  high 

1  It  has  been  calculated  that  in  the  supply  of  doctors  the  country  is  now  "about  thirty-five  years  in 
advance  of  the  requirements"!  Benedict :  Journal  of  American  Medical  Auociation,  vol.  lii.,  no.  5, 
pp.  378,  379. 

1  In  the  sixteen  schools  on  the  two-year  college  basis  there  were  (1908-9)  1850  students  who  had  en- 
tered at  that  level.  The  total  enrolment  in  these  sixteen  institutions  was  much  greater,  because  the 
upper  classes  in  several  had  entered  on  a  lower  basis.  These  figures  are  far  from  the  total  number  of 
college  men  in  medical  schools.  The  pity  is  that  they  are  scattered  through  institutions  in  which  they 
lose  the  advantage  which  their  education  should  give  them. 

*  Medical  Education:  Extract!  from  Lecture*  before  the  Johnt  Hopkins  Univertity,  1877-8,  p.  22  (Balti- 
more, 1878). 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  47 

school  to  the  college  standard  after  due  notice  given1  have  thus  far  lost  only  one- 
half  or  less  of  their  former  enrolment.  The  only  thing  that  falls  in  proportion  is  the 
income  from  fees ;  the  percentage  of  graduates  is  reduced  much  less.  At  the  Univer- 
sity of  Minnesota,  there  used  to  be  an  average  first-year  attendance  of  80  on  the 
high  school  basis;  on  the  two-year  college  basis  it  is  now  40;  at  Harvard  on  the 
former  basis,  160  new  matriculants;  now,  on  a  college  basis,  79.  Western  Reserve, 
with  34  on  the  high  school  basis,  advanced  suddenly  in  1901  to  a  three-year  college 
requirement;  the  enrolment  fell  to  12,  but  by  1908  the  loss  was  practically  recovered. 
Most  significant  is  the  demonstration  that  the  greatest  loss  is  due  to  the  transition 
from  the  high  school  or  equivalent  to  the  one-year  college  basis ;  the  rise  from  one 
to  two  years  of  college  has  relatively  little  effect  on  enrolment.  It  would  appear  that 
the  college  requirement  compels  deliberation.  Once  decided,  the  student  is  not  seri- 
ously hampered  by  the  effort  or  the  expense  of  an  additional  year. 

It  does  not  follow,  however,  that  if  schools  generally  rose  to  the  college  require- 
ment, their  losses  would  be  only  one-half  and  the  recovery  therefrom  ultimately  as- 
sured. For  the  schools  that  came  off  thus  lightly  were  previously  attended  by  a  large 
proportion  of  high-grade  men.2  A  much  greater  loss  would  undoubtedly  take  place 
in  the  lower-grade  schools;  many  of  them  would  be  practically  annihilated.  For  the 
tendency  of  elevated  standards  and  ideals  is  to  reduce  the  number  of  students  to 
something  like  parity  with  the  demand,  and  to  concentrate  this  reduced  student  body 
in  fewer  institutions,  adequately  supported. 

The  basis  which  we  have  urged  for  medical  education  gives  an  undoubted  advan- 
tage to  the  university  medical  departments.  We  shall  see  in  subsequent  chapters 
that  other  equally  important  factors  are  at  work  tending  to  restore  medical  educa- 
tion to  the  university  status ;  but  for  the  moment  the  difficulty  of  procuring  anywhere 
else  the  necessary  educational  foundation  is  perhaps  most  cogent.  A  countermove, 
by  way  of  avoiding  this  tendency,  has  recently  emanated  from  certain  Philadelphia 
schools,8  in  the  form  of  a  suggested  five-year  course,  the  first  year  to  be  devoted  to 
the  pre-medical  sciences. 

Several  serious  objections  to  this  proposition  may  be  urged:  (1)  a  single  year  is 
insufficient  for  three  laboratory  sciences,  and  makes  no  provision  for  modern  lan- 
guages; the  very  best  medical  schools  could  with  difficulty  give  one  year's  pre-medi- 

1  Cornell  changed  from  the  high  school  to  the  three-year  college  requirement  with  less  than  a  year's 
notice.  There  was,  of  course,  no  chance  to  readjust  matters;  the  next  first-year  class  (1908)  num- 
bered 15 ;  in  1909,  this  increased  to  23. 

2  In  these  schools  standards  were  elevated  in  advance  of  the  operation  of  the  formal  declaration  to 
that  effect.  For  example,  Columbia  (College  of  Physicians  ana  Surgeons,  New  York)  goes  to  the 
two-year  college  basis  1910-11 ;  but  the  entering  class  1909-10  contained  among  its  86  matriculates 
48  students  with  degrees,  and  1 1  more  who  had  had  two  years  of  college  work. 

3  These  schools  have  no  endowments ;  and  the  pre-medical  sciences  cannot  be  properly  taught  out  of 
fees,  as  will  become  evident  in  chapter  viii.,  "The  Financial  Aspects  of  Medical  Education.  "Hence  the 
work  must  be  mainly  make-believe.  It  would  have  to  be  given  by  already  overburdened  science 
teachers  or,  still  worse,  by  practitioners.  The  Medico-Chirurgical  College  of  Philadelphia  offers  these 
courses  "in  conjunction  with  classes  in  the  sister  department  of  pharmacy. "This  is  absurd. 


48 

cal  work, — they  cannot  possibly  give  two;  as  for  anything  more  liberal,  there  is  no 
chance  at  all.  Hence  the  step  would  shortly  prove  an  obstruction  to  further  progress. 
(2)  Unquestionably,  the  day  is  coming  when  the  medical  school  proper  will  want  a 
fifth  or  hospital  year, — a  culmination  that  will  be  indefinitely  postponed  if  the  year 
in  question  is  prefixed  to  the  course  and  assigned  to  preliminary  training.  (3)  Finally, 
the  arrangement  protracts  our  present  educational  disorganization.  It  proposes  that 
the  medical  school  should  do  the  work  of  the  college,  just  as  it  is  either  doing — or 
doing  without — the  work  of  the  high  school.  Now  the  strength  of  an  educational 
system  is  wholly  a  question  of  the  competent  performance  of  differentiated  function 
by  each  of  its  organic  parts.  Our  tardily  awakened  educational  conscience  and  in- 
telligence find  themselves  confronted  with  several  independent  and  detached  educa- 
tional agencies, — high  schools,  colleges,  professional  schools.  Obviously,  they  are 
not  indifferent  to  each  other;  they  belong  in  a  definite  order  and  relation.  We  now 
know  perfectly  well  what  that  order,  what  that  relation,  is.  And  the  solidity  of  our 
educational  and  scientific  progress  depends  on  our  success  in  making  it  prevail. 
To  no  inconsiderable  extent,  inefficiency  has  been  due  to  irresponsibility  resulting 
from  just  this  lack  of  organized  relationships;  and  the  cure  for  evils  due  to  lack 
of  responsibility  is  not  less  responsibility,  but  more;  not  less  differentiation,  but  more. 
The  reconstruction  of  our  medical  education  on  the  basis  of  two  years  of  required 
college  work  is  not,  however,  going  to  end  matters  once  and  for  all.  It  leaves  un- 
touched certain  outlying  problems  that  will  all  the  more  surely  come  into  focus  when 
the  professional  training  of  the  physician  is  once  securely  established  on  a  scientific 
basis.  At  that  moment  the  social  role  of  the  physician  will  generally  expand,  and  to 
support  such  expansion,  he  will  crave  a  more  liberal  and  disinterested  educational 
experience.  The  question  of  age — not  thus  far  important  because  hitherto  our  demands 
have  been  well  within  the  limits  of  adolescence — will  then  require  to  be  reckoned 
with.  The  college  freshman  averages  nineteen  years  of  age ;  two  years  of  college  work 
permit  him  to  begin  the  study  of  medicine  at  twenty-one,  to  be  graduated  at  twenty- 
five,  to  get  a  hospital  year  and  begin  practice  at  twenty-six  or  twenty-seven.  No  one 
familiar  with  the  American  college  can  lightly  ask  that  this  age  be  raised  two  years 
for  everybody,  for  the  sake  of  the  additional  results  to  be  secured  from  non-profes- 
sional college  work.  There  is,  however,  little  question  that  compression  in  the  ele- 
mentary school,  closer  articulation  between  and  more  effective  instruction  within 
secondary  school  and  college,  can  effect  economies  that  will  give  the  youth  of  twenty- 
one  the  advantage  of  a  complete  college  education.  The  basis  of  medical  education 
will  thus  have  been  broadened  without  deferring  the  actual  start.  Meanwhile  we  are 
so  far  from  endeavoring  to  force  a  single  iron-clad  standard  on  the  entire  country 
that  our  proposition  explicitly  recognizes  at  least  three  concurrent  levels  for  the 
time  being:  (1)  the  state  university  entrance  standard  in  the  south,  (2)  the  two-year 
college  basis  as  legal  minimum  in  the  rest  of  the  country,  (3)  the  degree  standard 
in  a  small  number  of  institutions. 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  49 

The  practical  problem  remains.  How  is  the  existing  situation  to  be  handled?  The 
higher  standard  is  alike  necessary  and  feasible.  How  long  is  it  to  be  postponed  be- 
cause it  threatens  the  existence  of  this  school  or  of  that?  In  general,  our  medical 
schools,  like  our  colleges,  are  local  institutions;  their  students  come  mainly  from 
their  own  vicinity.  The  ratio  of  physicians  to  population  in  a  given  state  is  there- 
fore a  fair  indication  of  the  number  of  medical  schools  needed.  Where  physicians  are 
superabundant,  and  high  schools  and  colleges  at  least  not  lacking,  the  medical 
schools  cannot  effectively  plead  for  mercy  on  the  ground  that  elevated  standards 
will  be  their  death.  New  York  has  two  schools  on  the  two-year  college  basis  or  bet- 
ter; nine  others  rest  on  a  lower  basis.  They  would  improve  if  they  could  "afford 
it."1  But  with  one  doctor  for  every  600  people  in  the  state,  with  accessible  high  schools, 
with  cheap — and  in  New  York  City,  at  least,  free — colleges,  it  is  absolutely  immate- 
rial to  the  public  whether  they  can  afford  it  or  not.  The  public  interest  demands  the 
change.  We  may  therefore  at  once  assume  (what  everybody  grants)  that  the  problem 
is  insoluble  on  the  basis  of  the  survival  of  all  or  most  of  our  present  medical  schools. 
To  live,  they  must  get  students ;  they  must  get  them  far  in  excess  of  the  number 
they  will  graduate;  they  must  graduate  them  far  in  excess  of  the  number  of 
doctors  needed.  They  will  therefore  require  their  clientele  of  ill  prepared,  discon- 
tented, drifting  boys,  accessible  to  successful  solicitation  on  commercial  lines.  In- 
evitably, then,  the  way  to  better  medical  education  lies  through  fewer  medical  \ 
schools ;  but  legal  enactments  on  the  subject  of  medical  education  and  practice  will 
be  required  before  the  medical  schools  will  either  give  up  or  relate  themselves  soundly 
to  the  educational  resources  of  their  respective  states.  No  general  legislation  is  at  the 
moment  feasible.  The  south,  for  instance,  may  well  rest  for  a  time,  if  every  state  will 
at  once  restrict  examinations  for  license  to  candidates  actually  possessing  the  M.D. 
degree,  and  require  after,  say,  January  1,  1911,  that  every  such  degree  shall  ema- 
nate from  a  medical  school  whose  entrance  standards  are  at  least  those  of  the  state 
university.  Such  legislation  would  suppress  the  schools  that  now  demoralize  the  situ- 
ation; it  would  concentrate  the  better  students  in  a  few  solvent  institutions  to  which 
the  next  moves  may  safely  be  left.  Elsewhere,  every  available  agency  should  be  em- 
ployed to  bring  examining  boards  to  reinterpret  the  word  "equivalent"  and  to  adopt 
efficient  machinery  for  the  enforcement  of  the  intended  standard.  Equivalent  means 
"equal  in  force,  quality,  and  effect."  The  only  authorities  competent  to  pass  on  such 
values  are  trained  experts.  The  entire  matter  would  be  in  their  hands  if  the  state  boards 
should  in  every  state  delegate  the  function  of  evaluating  entrance  credentials  to  a 
competently  organized  institution  of  learning.  In  many  states,  the  state  university 

1The  dean  of  a  superfluous  southern  medical  school  writes  :  "Our  faculty  gets  only  what's  left  after 
all  expenses  are  paid,  and  that  averages  $400  per  session  of  seven  months.  This  we  will  cheerfully 
forego,  and  teach  gratis,  if  only  a  class,  or  endowment,  will  pay  cost  of  running  the  college.  We  will 
advance  to  the  highest  requirements  just  as  soon  as  the  conditions  will  admit,  and  are  ready  now  to 
open  next  session  under  highest  requirements  if  the  wherewith  to  pay  expenses  is  in  sight"  Ob- 
serve that  there  is  small  consideration  here  for  the  "poor  boy"  or  the  "back  country;"  it  is  simply 
a  question  of  college  survival. 


50  MEDICAL  EDUCATION 

could  very  properly  perform  this  duty ;  elsewhere,  an  equally  satisfactory  arrangement 
could  be  made  with  an  endowed  institution.  Whatever  the  standard  fixed,  it  would 
thus  be  intelligently  enforced.  The  school  catalogues  would  then  announce  that  no 
student  can  be  matriculated  whose  credentials  are  not  filed  within  ten  days  of  the 
opening  of  the  session,  and  that  no  M.  D.  degree  can  be  conferred  until  at  least  four 
years  subsequent  to  complete  satisfaction  of  the  preliminary  requirement.  These  cre- 
dentials, sent  at  once  to  the  secretary  of  the  state  board,  would  be  by  him  turned 
over  to  the  registrar  of  the  state  or  other  university,  whose  verdict  would  be  final. 
A  state  that  desired  to  enforce  a  four-year  high  school  requirement  could  specify  as 
satisfying  its  requirements: 

(1)  Certificate  of  admission  to  a  state  university  requiring  a  four-year  high  school 
education ; 

(2)  Certificate  of  admission  to  any  institution  that  is  a  member  of  the  Association 
of  American  Universities; 

(3)  Medical  Student  Certificate  of  the  Regents  of  the  University  of  the  State  of 
New  York; 

(4)  Certificates  issued  by  the  College  Entrance  Examination  Board  for  14-  units. 
In  exchange  for  such  credentials,  or  for  high  school  diplomas  acceptable  to  the 

academic  authorities  acting  for  the  state  board,  a  medical  student  certificate  would 
be  issued;  in  default  thereof,  the  student  must  by  examination  earn  one  of  the  afore- 
said credentials,  in  its  turn  to  be  made  the  basis  of  his  medical  student  certificate. 
In  the  southern  states,  the  legal  minimum  would  be  necessarily  below  the  four-year 
high  school;  in  Minnesota,  above  it.  But  the  same  sort  of  machinery  would  work. 
The  schools  would  have  nothing  to  do  with  it  except  to  keep  systematically  regis- 
tered the  name  of  the  student  and  the  number  of  his  certificate;  the  state  board  or 
the  university  acting  for  it  would  keep  everything  else,  open  to  inspection. 

This  is  substantially  what  takes  place  in  New  York,  where  the  State  Education  De- 
partment superintends  the  process.  What  is  wanted  in  other  states  is  an  agency 
similarly  qualified.  For  the  present  nothing  can  so  well  perform  the  office  within  a 
given  state  as  its  state  university,  or,  in  default  thereof,  the  best  of  its  endowed  in- 
stitutions. This  suggestion  is  perfectly  fair  to  all  medical  schools,  for  the  credentials 
would  pass  through  the  hands  of  the  state  board  to  the  reviewing  authority  without 
information  as  to  the  purpose  of  the  applicant.  The  directions  required  would  take 
up  less  space  in  the  medical  school  catalogues  than  the  complicated  details  they  now 
contain.  It  should  be  further  provided  that  the  original  credentials  of  every  student 
be  kept  on  file  in  the  office  of  the  state  board  or  the  reviewing  university,  and  that 
they  shall  be  open  to  inspection,  without  notice,  by  properly  accredited  representa- 
tives of  medical  and  educational  organizations.  These  simple  measures  would  intro- 
duce intelligence  and  sincerity  where  subterfuge  and  disorder  now  prevail.  The  bene- 
ficial results  to  the  high  school  and  the  medical  school  would  be  incalculable.  Nor 
would  the  poor  boy  be  subjected  to  the  least  hardship;  for  by  exercising  forethought, 


ACTUAL  BASIS  OF  MEDICAL  EDUCATION  51 

he  could  accumulate  genuine  scholastic  credits  by  examination  or  otherwise,  pari 
passu,  during  the  time  he  is  accumulating  the  money  for  his  medical  education.  So 
much  actually  accomplished,  the  rest  will  be  easier.  The  reduced  number  of  schools 
will  not  resist  the  forces  making  for  a  higher  legal  minimum.  The  state  universities 
of  the  west  will  doubtless  lead  this  movement;  for  once  established  on  the  two-year 
college  basis,  they  will  induce  the  states  to  protect  their  own  sons  and  the  public 
health  against  the  lower-grade  doctors  made  elsewhere.  The  University  of  Minnesota,  j 
having  by  statesmanlike  action  got  rid  of  all  other  medical  schools  in  the  state,  is  thus  1 
backed  up  by  the  legislature  and  the  state  board.  North  Dakota  and  Indiana  have 
taken  the  same  stand.  Michigan  and  Iowa  will  probably  soon  follow.  "The  adjust- 
ment is  perhaps  difficult,  but  not  too  difficult  for  American  strength."1 


1  Adapted  from  Billroth:  Ueber  das  Lehren  und  L«rn«n  d*r  medicinischen  Wiuenachaft,  quoted  by 
Lewis,  loc.  cit. 


CHAPTER  IV 

THE  COURSE  OF  STUDY:  THE  LABORATORY  BRANCHES 

(A)  FIRST  AND  SECOND  YEARS 

THREE  characteristic  stages  are  to  be  discerned  in  the  evolution  of  medical  teaching.1 
The  first  and  longest  was  the  era  of  dogma.  Its  landmarks  are  Hippocrates  (B.C.  460- 
377)  and  Galen  (A.  D.  130-200),  whose  writings  were  for  centuries  transmitted  as  an 
authoritative  canon.  Observation  and  experience  had  indeed  figured  considerably  in 
their  composition,8  but  increasingly  remote  disciples  in  accepting  the  tradition  lost 
all  interest  in  its  source.  The  Galenic  system  took  its  place  in  the  medieval  univer- 
sity with  Euclid  and  Aristotle, — a  thing  to  be  pondered,  expounded  and  learned; 
facts  had  no  chance  if  pitted  against  the  word  of  the  master.  So  completely  was 
medicine  dominated  by  scholasticism  that  surgery,  employing  such  base  tools  as  sight 
and  touch,  was  held  to  be  something  less  than  a  trade  and  accordingly  excluded 
from  intellectual  company. 

The  second  era  is  that  of  the  empiric.  It  began  with  the  introduction  of  anatomy 
in  the  sixteenth  century,  but  did  not  reach  its  zenith  until  some  two  hundred  years 
later.  At  its  best  it  leaned  upon  experience,  but  its  means  of  analyzing,  classifying^ 
and  interpreting  phenomena  were  painfully  limited.  Medical  art  was  still  under  the 
sway  of  preconceived  and  preternatural  principles  of  explanation ;  and  rigorous  ther- 
apeutic measures  were  not  uncommonly  deduced  from  purely  metaphysical  assump- 
tions. The  debility  of  yellow  fever,  for  example,  Rush  explained  by  "the  oppressed 
state  of  the  system;"  and  on  the  basis  of  a  gratuitous  abstraction,  resorted  freely  to 
purging  and  bleeding.  His  first  four  patients  recovered;  there  is  no  telling  how  many 
lives  were  subsequently  sacrificed  to  this  conclusive  demonstration.  The  fact  is  that 
the  empiric  lacked  a  technique  with  which  to  distinguish  between  apparently  similar 
phenomena,  to  organize  facts,  and  to  check  up  observation;  the  art  of  differentiation 
through  controlled  experimentation  was  as  yet  in  its  infancy.  Under  vague  labels 
like  rheumatism,  biliousness,  malaria,  or  congestion,  a  hodgepodge  of  dissimilar  and 
unrelated  conditions  were  uncritically  classed;  the  names  meant  nothing,  but  they 
answered  as  explanation,  and  even  sanctioned  severe  and  nauseous  medication.  Igno- 
rant of  causes,  the  shrewdest  empiric  thus  continued  to  confound  totally  unlike 
conditions  on  the  basis  of  superficial  symptomatic  resemblance;  and  with  amazing 
assurance  undertook  to  employ  in  all  a  therapeutic  procedure  of  doubtful  value  in 
any.  He  combined  the  vehemence  of  the  partisan  with  something  of  the  credulity  of 

1  Nothing  would  do  more  to  orient  the  student  intelligently  than  a  knowledge  of  the  history  of 
medical  science  and  teaching.  It  is  a  great  pity  that  some  effort  is  not  made  in  the  better  medical 
schools  to  interest  the  student  in  the  subject.  A  proper  historical  perspective  would  render  impos- 
sible such  opposition  to  improved  medical  teaching  as  is  now  based  on  conscientious  but  mistaken 
devotion  to  outgrown  conditions. 

*"The  correct  inductive  method  was  borne  in  on  the  triumph  of  Hippocrates."  Compere's  Greek 
Thinluri  (translated  by  Magnus,  vol.  i.  p.  308). 


THE  LABORATORY  BRANCHES  53 

a  child,  persuading  too  often  by  ardent  insistence  rather  than  by  logical  proof.  His 
students  were  thus  passive  learners,  even  where  the  teaching  was  demonstrative. 
They  studied  anatomy  by  watching  a  teacher  dissect;  they  studied  therapeutics  by 
taking  the  word  of  the  lecturer  or  of  the  text-book  for  the  efficacy  of  particular 
remedies  in  certain  affections. 

The  third  era  is  dominated  by  the  knowledge  that  medicine  is  part  and  parcel 
of  modern  science.  The  human  body  belongs  to  the  animal  world.  It  is  put  together 
of  tissues  and  organs,  in  their  structure,  origin,  and  development  not  essentially  un- 
like what  the  biologist  is  otherwise  familiar  with ;  it  grows,  reproduces  itself,  decays, 
according  to  general  laws.  It  is  liable  to  attack  by  hostile  physical  and  biological 
agencies ;  now  struck  with  a  weapon,  again  ravaged  by  parasites.  The  normal  course 
of  bodily  activity  is  a  matter  of  observation  and  experience;  the  best  methods  of 
combating  interference  must  be  learned  in  much  the  same  way.  Gratuitous  specu- 
lation is  at  every  stage  foreign  to  the  scientific  attitude  of  mind. 

We  may  then  fairly  describe  modern  medicine  as  characterized  by  a  severely  criti- 
cal handling  of  experience.  It  is  at  once  more  skeptical  and  more  assured  than  mere 
empiricism.  For  though  it  takes  nothing  on  faith,  the  fact  which  it  accepts  does  not 
fear  the  hottest  fire.  Scientific  medicine  is,  however,  as  yet  by  no  means  all  of  one 
piece;  uniform  exactitude  is  still  indefinitely  remote;  fortunately,  scientific  integrity 
does  not  depend  on  the  perfect  homogeneity  of  all  its  data  and  conclusions.  Modern 
medicine  deals,  then,  like  empiricism,  not  only  with  certainties,  but  also  with  pro- 
babilities, surmises,  theories.  It  differs  from  empiricism,  however,  in  actually  know- 
ing at  the  moment  the  logical  quality  of  the  material  which  it  handles.  It  knows,  as 
empiricism  never  knows,  where  certainties  stop  and  risks  begin.  Now  it  acts  confi- 
dently, because  it  has  facts;  again  cautiously,  because  it  merely  surmises;  then  tenta- 
tively, because  it  hardly  more  than  hopes.  The  empiric  and  the  scientist  both  theo- 
rize, but  logically  to  very  different  ends.  The  theories  of  the  empiric  set  up  some 
unverifiable  existence  back  of  and  independent  of  facts, — a  vital  essence,  for  example; 
the  scientific  theory  is  in  the  facts, — summing  them  up  economically  and  suggesting 
practical  measures  by  whose  outcome  it  stands  or  falls.  Scientific  medicine,  therefore, 
has  its  eyes  open;  it  takes  its  risks  consciously;  it  does  not  cure  defects  of  knowledge 
by  partisan  heat;  it  is  free  of  dogmatism  and  open-armed  to  demonstration  from 
whatever  quarter. 

On  the  pedagogic  side,  modern  medicine,  like  all  scientific  teaching,  is  character- 
ized by  activity.  The  student  no  longer  merely  watches,  listens,  memorizes;  he  does. 
His  own  activities  in  the  laboratory  and  in  the  clinic  are  the  main  factors  in  his  in- 
struction and  discipline.  An  education  in  medicine  nowadays  involves  both  learning 
and  learning  how;  the  student  cannot  effectively  know,  unless  he  knows  how. 

Two  circumstances  have  mediated  the  transformation  from  empirical  to  scientific 
medicine:  the  development  of  physics,  chemistry,  and  biology;  the  elaboration  out 
of  them  of  a  method  just  as  applicable  to  practice  as  to  research.  The  essential  de- 


54  MEDICAL  EDUCATION 

pendence  of  modern  medicine  on  the  physical  and  biological  sciences,  already  ad- 
verted to,1  will  hereafter  become  increasingly  obvious  in  the  wealth  of  the  curricula 
based  upon  them,  and  no  less  in  the  poverty  of  those  constructed  without  them. 
But  the  practical  importance  of  scientific  method  as  such  to  the  general  practitioner 
is  by  no  means  so  generally  conceded.  Its  function  in  investigation  is  granted :  there 
it  is  justified  by  its  own  fruits.  But  what  has  this  to  do  with  the  education  or  the 
daily  routine  of  the  family  doctor? 

The  question  raised  is  fundamental;  the  answer  decides  the  sort  of  medical  edu- 
cation that  we  shall  seek  generally  to  provide.  If,  in  a  word,  scientific  method  and 
interest  are  of  slight  or  no  importance  to  the  ordinary  practitioner  of  medicine,8  we 
shall  permanently  establish  two  types  of  school, — the  scientific  type,  in  which  en- 
lightened and  progressive  men  may  be  trained;  the  routine  type,  in  which  "family 
doctors'"  may  be  ground  out  wholesale.  If,  on  the  other  hand,  scientific  method  is 
just  as  valuable  to  the  practitioner  as  to  the  investigator,  it  may  indeed  be  expe- 
dient partly,  or  even  in  some  instances  altogether,  to  set  aside  gifted  individuals  as 
teachers  or  investigators  and  to  guard  the  undergraduate  student  against  original 
work  prematurely  undertaken.  But  this  will  not  be  construed  to  involve  the  abrupt 
and  total  segregation  of  medical  education  from  medical  research.  Much  of  the  edu- 
cator's duty  may  consist  in  traversing  a  well  known  path;  but  if  otherwise  he  is  pro- 
gressively busy,  the  well  known  path  will  never  look  exactly  the  same  twice.  The 
medical  school  will  in  that  case  be  more  than  the  undergraduate  curriculum.  Ac- 
tivities will  be  in  progress  that  at  every  point  run  beyond  the  undergraduate^ 
capacity  and  interest  at  the  moment.  But  the  undergraduate  curriculum  will  not 
differ  in  spirit,  method,  or  aspiration  from  the  interests  that  transcend  it. 

The  conservative  in  medical  education  makes  much  of  what  he  conceives  to  be  a 
fundamental  opposition  between  medical  practice  and  medical  science;  occasionally 
a  despairing  progressive  accepts  it.  The  family  doctor  represents  the  former  type. 
One  can  ask  of  him — so  the  conservative  thinks — only  that  he  be  more  or  less  well 
grounded  in  things  as  they  are  when  he  gets  his  degree.  The  momentum  with  which 
he  is  propelled  from  the  medical  school  must  carry  him  to  the  end  of  his  days, — on  a 
gradually  declining  curve;  but  that  cannot  be  helped.  The  other  type — the  scien- 
tific doctor — either  himself  "investigates,"  or  has  a  turn  for  picking  up  increases 
due  to  others.  How  profound  is  the  opposition  here  depicted  ?  Opposition  of  course 
there  is  between  all  things  in  respect  to  time  and  energy.  The  doctor  who  puts  on 
his  hat  and  goes  out  to  see  a  sick  baby  cannot  just  then  be  making  an  autopsy  on  a 
guinea-pig  dead  of  experimental  dysentery.  But  does  the  opposition  go  any  deeper? 
Is  there  any  logical  incompatibility  between  the  science  and  the  practice  of  medi- 
cine? 

1  Chapter  ii.  p.  24. 

1  This  is  the  common  contention  of  the  routine  schools  that  run  on  low  admission  requirements  and 
employ  practitioner  teachers. 


THE  LABORATORY  BRANCHES  55 

The  main  intellectual  tool  of  the  investigator  is  the  working  hypothesis,  or  theory, 
as  it  is  more  commonly  called.  The  scientist  is  confronted  by  a  definite  situation;  he 
observes  it  for  the  purpose  of  taking  in  all  the  facts.  These  suggest  to  him  a  line  of 
action.  He  constructs  a  hypothesis,  as  we  say.  Upon  this  he  acts,  and  the  practical 
outcome  of  his  procedure  refutes,  confirms,  or  modifies  his  theory.  Between  theory 
and  fact  his  mind  flies  like  a  shuttle;  and  theory  is  helpful  and  important  just  to 
the  degree  in  which  it  enables  him  to  understand,  relate,  and  control  phenomena. 

This  is  essentially  the  technique  of  research:  wherein  is  it  irrelevant  to  bedside 
practice?  The  physician,  too,  is  confronted  by  a  definite  situation.  He  must  needs 
seize  its  details,  and  only  powers  of  observation  trained  in  actual  experimentation 
will  enable  him  to  do  so.  The  patient's  history,  conditions,  symptoms,  form  his  data. 
Thereupon  he,  too,  frames  his  working  hypothesis,  now  called  a  diagnosis.  It  sug- 
gests a  line  of  action.  Is  he  right  or  wrong?  Has  he  actually  amassed  all  the  signifi- 
cant facts?  Does  his  working  hypothesis  properly  put  them  together?  The  sick  man's 
progress  is  nature's  comment  and  criticism.  The  professional  competency  of  the 
physician  is  in  proportion  to  his  ability  to  heed  the  response  which  nature  thus 
makes  to  his  ministrations.  The  progress  of  science  and  the  scientific  or  intelligent 
practice  of  medicine  employ,  therefore,  exactly  the  same  technique.  To  use  it,  whether 
in  investigation  or  in  practice,  the  student  must  be  trained  to  the  positive  exercise 
of  his  faculties;  and  if  so  trained,  the  medical  school  begins  rather  than  completes  his 
medical  education.  It  cannot  in  any  event  transmit  to  him  more  than  a  fraction  of 
the  actual  treasures  of  the  science;  but  it  can  at  least  put  him  in  the  way  of  steadily 
increasing  his  holdings.  A  professional  habit  definitely  formed  upon  scientific  method 
will  convert  every  detail  of  his  practising  experience  into  an  additional  factor  in  his 
effective  education. 

From  the  standpoint  of  the  young  student,  the  school  is,  of  course,  concerned 
chiefly  with  his  acquisition  of  the  proper  knowledge,  attitude,  and  technique.  Once 
more,  it  matters  not  at  that  stage  whether  his  destination  is  to  be  investigation  or 
practice.  In  either  case,  as  beginner,  he  learns  chiefly  what  is  old,  known,  understood. 
But  the  old,  known,  and  understood  are  all  alike  new  to  him ;  and  the  teacher  in  pre- 
senting it  to  his  apprehension  seeks  to  evoke  the  attitude,  and  to  carry  him  through 
the  processes,  of  the  thinker  and  not  of  the  parrot. 

The  fact  that  disease  is  only  in  part  accurately  known  does  not  invalidate  the 
scientific  method  in  practice.  In  the  twilight  region  probabilities  are  substituted  for 
certainties.  There  the  physician  may  indeed  only  surmise,  but,  most  important  of 
all,  he  knows  that  he  surmises.  His  procedure  is  tentative,  observant,  heedful,  re- 
sponsive. Meanwhile  the  logic  of  the  process  has  not  changed.  The  scientific  physician 
still  keeps  his  advantage  over  the  empiric.  He  studies  the  actual  situation  with 
keener  attention;  he  is  freer  of  prejudiced  prepossession;  he  is  more  conscious  of 
liability  to  error.  Whatever  the  patient  may  have  to  endure  from  a  baffling  disease, 
he  is  not  further  handicapped  by  reckless  medication.  In  the  end  the  scientist  alone 


56  MEDICAL  EDUCATION 

draws  the  line  accurately  between  the  known,  the  partly  known,  and  the  unknown. 
The  empiricist  fares  forth  with  an  indiscriminate  confidence  which  sharp  lines  do 
not  disturb. 

Investigation  and  practice  are  thus  one  in  spirit,  method,  and  object.  What  is 
apt  to  be  regarded  as  a  logical,  is  really  but  a  practical,  difficulty,  due  to  the  neces- 
sity for  a  division  of  labor.  "The  golden  nuggets  at  or  near  the  surface  of  things 
have  been  for  the  greater  part  discovered,  it  seems  safe  to  say.  We  must  dig  deeper 
to  find  new  ones  of  equal  value,  and  we  must  often  dig  circuitously,  with  mere  hints 
for  guides."1  If,  then,  we  differentiate  investigator  and  practitioner,  it  is  because 
in  the  former  case  action  is  leisurely  and  indirect,  in  the  latter  case,  immediate  and 
anxious.  The  investigator  swings  around  by  a  larger  loop.  But  the  mental  qualities 
involved  are  the  same.  They  employ  the  same  method,  the  same  sort  of  intelli- 
gence. And  as  they  get  their  method  and  develop  their  intelligence  in  the  first 
place  at  school,  it  follows  that  the  modern  medical  school  will  be  a  productive  as 
well  as  a  transmitting  agency.  An  exacting  discipline  cannot  be  imparted  except 
in  a  keen  atmosphere  by  men  who  are  themselves  "in  training."  Of  course  the  busi- 
ness of  the  medical  school  is  the  making  of  doctors;  nine-tenths  of  its  graduates  will, 
as  Dr.  Osier  holds,  never  be  anything  else.  But  practitioners  of  modern  medicine 
must  be  alert,  systematic,  thorough,  critically  open-minded;  they  will  get  no  such 
training  from  perfunctory  teachers.  Educationally,  then,  research  is  required  of  the 
medical  faculty  because  only  research  will  keep  the  teachers  in  condition.  A  non-pro- 
ductive school,  conceivably  up  to  date  to-day,  would  be  out  of  date  to-morrow ;  its 
dead  atmosphere  would  soon  breed  a  careless  and  unenlightened  dogmatism. 

Teachers  of  modern  medicine,  clinical  as  well  as  scientific,  must,  then,  be  men  of 
active,  progressive  temper,  with  definite  ideals,  exacting  habits  in  thought  and 
work,  and  with  still  some  margin  for  growth.  No  inconsiderable  part  of  their  energy 
and  time  is  indeed  absorbed  in  what  is  after  all  routine  instruction;  for  their  situa- 
tion differs  vastly  from  that  of  workers  in  non-teaching  institutions  devoted  wholly 
to  investigation.  Their  practical  success  depends,  therefore,  on  their  ability  to  carry 
into  routine  the  rigor  and  the  vigor  of  their  research  moments.  A  happy  adjust- 
ment is  in  this  matter  by  no  means  easy ;  nor  has  it  been  as  yet  invariably  reached. 
Investigators,  impressed  with  the  practical  importance  of  scientific  method  to  the 
practising  physician,  tend  perhaps  to  believe  that  it  is  to  be  acquired  only  in  origi- 
nal research.  A  certain  impatience  therefore  develops,  and  ill  equipped  student  barks 
venture  prematurely  into  uncharted  seas.  But  the  truth  is  that  an  instructor,  devot- 
ing part  of  his  day  under  adequate  protection  to  investigation,  can  teach  even  the 
elements  of  his  subject  on  rigorously  scientific  lines.  On  the  other  hand,  it  will  never 
happen  that  every  professor  in  either  the  medical  school  or  the  university  faculty 
is  a  genuinely  productive  scientist.  There  is  room  for  men  of  another  type, — the 

1 C.  A.  Herter :  "  Imagination  and  Idealism  in  the  Medical  Sciences,"  Columbia  Univ.  Quart.,  vol.  xii., 
DO.  11,  p.  16. 


THE  LABORATORY  BRANCHES  57 

non-productive,  assimilative  teacher  of  wide  learning,  continuous  receptivity,  critical 
sense,  and  responsive  interest.  Not  infrequently  these  men,  catholic  in  their  sympa- 
thies, scholarly  in  spirit  and  method,  prove  the  purveyors  and  distributors  through 
whom  new  ideas  are  harmonized  and  made  current.  They  preserve  balance  and  make 
connections.  The  one  person  for  whom  there  is  no  place  in  the  medical  school,  the 
university,  or  the  college,  is  precisely  he  who  has  hitherto  generally  usurped  the 
medical  field, — the  scientifically  dead  practitioner,  whose  knowledge  has  long  since 
come  to  a  standstill  and  whose  lectures,  composed  when  he  first  took  his  chair,  like 
pebbles  rolling  in  a  brook  get  smoother  and  smoother  as  the  stream  of  time  washes 
over  them. 

The  student  is  throughout  to  be  kept  on  his  mettle.  He  does  not  have  to  be  a 
passive  learner,  just  because  it  is  too  early  for  him  to  be  an  original  explorer.  He 
can  actively  master  and  securely  fix  scientific  technique  and  method  in  the  process 
of  acquiring  the  already  known.  From  time  to  time  a  novel  turn  may  indeed  give 
zest  to  routine;  but  the  undergraduate  student  of  medicine  will  for  the  most  part  ac- 
quire the  methods,  standards,  and  habits  of  science  by  working  over  territory  which 
has  been  traversed  before,  in  an  atmosphere  freshened  by  the  search  for  truth. 

For  purposes  of  convenience,  the  medical  curriculum  may  be  divided  into  two 
parts,  according  as  the  work  is  carried  on  mainly  in  laboratories  or  mainly  in  the 
hospital;  but  the  distinction  is  only  superficial,  for  the  hospital  is  itself  in  the  full- 
est sense  a  laboratory.  In  general,  the  four-year  curriculum  falls  into  two  fairly  equal 
sections:  the  first  two  years  are  devoted  mainly1  to  laboratory  sciences, — anatomy, 
physiology,  pharmacology,  pathology;  the  last  two  to  clinical  work  in  medicine, 
surgery,  and  obstetrics.  The  former  are  concerned  with  the  study  of  normal  and 
abnormal  phenomena  as  such ;  the  latter  are  busy  with  their  practical  treatment  as 
manifested  in  disease.  How  far  the  earlier  years  should  be  at  all  conscious  of  the 
latter  is  a  mooted  question.  Anatomy  and  physiology  are  ultimately  biological  sci- 
ences. Do  the  professional  purposes  of  the  medical  school  modify  the  strict  biologi- 
cal point  of  view  ?  Should  the  teaching  of  anatomy  and  physiology  be  affected  by 
the  fact  that  these  subjects  are  parts  of  a  medical  curriculum  ?  Or  ought  they  be 
presented  exactly  as  they  would  be  presented  to  students  of  biology  not  intending 
to  be  physicians?  A  layman  hesitates  to  offer  an  opinion  where  the  doctors  disagree, 
but  the  purely  pedagogical  standpoint  may  assist  a  determination  of  the  issue.  Per- 
haps a  certain  misconception  of  what  is  actually  at  stake  is  in  a  measure  responsible 
for  the  issue.  Scientific  rigor  and  thoroughness  are  not  in  question.  Whatever  the 
point  of  view — whether  purely  biological  or  medical  —  scientific  method  is  equally 
feasible  and  essential ;  a  verdict  favorable  to  recognition  of  the  explicitly  medical 
standpoint  would  not  derogate  from  scientific  rigor.  There  is  no  doubt  that  the 
sciences  in  question  can  be  properly  cultivated  only  in  the  university  in  their  entirety 

*An  introductory  course  in  physical  diagnosis  is  given  in  the  second  year;  occasionally  clinical  work 
is  begun  in  its  latter  half. 


58  MEDICAL  EDUCATION 

and  in  close  association  with  contiguous,  contributory,  or  overlapping  sciences.  No 
one  of  them  is  sharply  demarcated ;  at  any  moment  a  lucky  stroke  may  transfer  a 
problem  from  pathology  to  chemistry  or  biology.  There  are  indeed  no  problems  in 
pathology  which  are  not  simultaneously  problems  of  chemistry  and  biology  as  well. 
So  far  the  rigorously  and  disinterestedly  scientific  viewpoint  is  valid.  These  con- 
siderations, however,  still  omit  one  highly  important  fact:  medical  education  is  a 
technical  or  professional  discipline;  it  calls  for  the  possession  of  certain  portions  of 
many  sciences  arranged  and  organized  with  a  distinct  practical  purpose  in  view.  That 
is  what  makes  it  a  "profession."  Its  point  of  view  is  not  that  of  any  one  of  the  sciences 
as  such.  It  is  difficult  to  see  how  separate  acquisitions  in  several  fields  can  be  organi- 
cally combined,  can  be  brought  to  play  upon  each  other,  in  the  realization  of  a  con- 
trolling purpose,  unless  this  purpose  is  consciously  present  in  the  selection  and  mani- 
pulation of  the  material.  Pathology,  for  example,  is  a  study  of  abnormal  structure 
and  function ;  the  pathologist  as  such  works  intensively  within  a  circumscribed  field. 
For  the  time  being,  it  pays  him  to  ignore  bearings  and  complications  outside  his  im- 
mediate territory.  Undoubtedly,  the  progressive  pathologist  will  always  be  at  work 
upon  certain  problems,  thus  temporarily,  but  only  temporarily,  isolated.  But  in  the 
undergraduate  class-room  he  is  from  time  to  time  under  necessity  of  escaping  these 
limitations :  there  he  is  engaged  in  presenting  things  in  their  relations.  The  autopsy, 
the  clinical  history,  will  be  utilized  in  presenting  to  the  student,  even  if  incidentally, 
the  total  picture  of  disease.  Similarly,  the  anatomist  can  score  many  a  point  for  the 
physiologist  without  actually  forestalling  him.  He  views  the  body  not  as  a  mosaic 
to  be  broken  up,  but  as  a  machine  to  be  taken  to  pieces,  the  more  perfectly  to  com- 
prehend how  it  works.  The  pharmacologist  is  in  a  similar  relation  to  the  clinician. 
The  principles  of  bacteriology  lose  nothing  in  scientific  exactitude  because,  taught 
as  a  part  of  the  medical  curriculum,  they  are  enforced  with  illustrations  from  the  bac- 
terial diseases  of  man  rather  than  from  those  of  animals  and  plants;  and  histology  is  not 
the  less  histology  because  tissues  from  the  human  body  are  preferably  employed.1  In 

JThe  following  quotations  from  "An  Outline  of  the  Course  in  Normal  Histology,"  by  L.  F.  Barker 
and  C.  R.  Bardeen  (John*  Hopkins  Hospital  Bulletin,  vol.  vii.,  nos.  62,  63,  p.  100,  etc.),  forcibly  illus- 
trate the  above  contention. 

"  In  deciding  as  to  the  plan  to  Ke  adopted  we  have  been  much  influenced,  too,  by  the  fact  that  our 
students  are  students  of  medicine.  Thus  it  will  be  noticed  that  in  the  selection  of  tissues,  those  from 
the  human  body  make  up  a  large  part  of  the  material  used ;  and  when  animal  tissues  are  employed, 
special  care  has  been  taken  to  point  out  how  they  differ  from  the  human.  Moreover,  in  deciding  what 
to  exclude  from  the  course  thought  was  given  to  the  bearing  of  the  specimens  on  the  practical  work 
in  medicine  which  was  to  follow,  and  stress  was  laid  upon  those  portions  of  human  histology  which 
previous  experience  has  taught  us  are  of  the  most  importance  in  the  appreciation  and  interpretation 
of  the  pathological  alterations  in  disease.  In  the  present  status  of  pathological  histology  a  knowledge 
of  certain  details  is  of  much  greater  value  than  that  of  others ;  and  for  the  student  entering  medicine, 
a  judicious  selection  of  what  shall  be  given  and  what  shall  be  left  out  should  be  made  by  some  one 
who  has  had  a  more  or  less  wide  training  in  pathological  histology. 

"  Further  bearing  in  mind  the  life-work  for  which  the  student  is  preparing  himself,  we  have  not 
always  chosen  the  method  which  would  show  the  finest  structural  details  of  the  tissues.  While  the 
most  delicate  methods  have  been  introduced  in  places,  we  have  endeavored  to  familiarize  the  stu- 
dents with  a  large  number  of  different  modes  of  preparation.  The  student  who  has  been  brought  up 
entirely  on  'gilt-edged'  histological  methods  will  find  himself  sadly  at  a  loss  in  battling  with  the 
•rough  and  ready '  world  in  which  the  pathologist  has  to  live."  (Somewhat  abridged.) 


THE  LABORATORY  BRANCHES  59 

short,  research,  untrammeled  by  near  reference  to  practical  ends,  will  go  on  in  every 
properly  organized  medical  school;  its  critical  method  will  dominate  all  teaching 
whatsoever ;  but  undergraduate  instruction  will  be  throughout  explicitly  conscious 
of  its  professional  end  and  aim.  In  no  other  way  can  all  the  sciences  belonging  to 
the  medical  curriculum  be  thoroughly  kneaded.  An  active  apperceptive  relation  must 
be  established  and  maintained  between  laboratory  and  clinical  experience.  Such  a  re- 
lation cannot  be  one-sided;  it  will  not  spontaneously  set  itself  up  in  the  last  two 
years  if  it  is  deliberately  suppressed  in  the  first  two.  There  is  no  cement  like  interest, 
no  stimulus  like  the  hint  of  a  coming  practical  application.1 

Medical  reference,  in  the  sense  that  the  laboratory  sciences  should,  while  freely 
presented,  be  kept  conscious  of  their  membership  in  the  medical  curriculum,  has  been 
discredited  in  this  country,  because  it  had  so  long  meant  a  mechanical  drill  in  an 
inert  outline  of  the  several  sciences  by  untrained  and  busy  practitioners.  In  the  ef- 
fort to  teach  the  modicum  of  chemistry  or  physiology  or  pathology  that  "the  family 
doctor  needs  to  know,"  they  neglected  to  teach  anything  of  permanent  scientific 
value  at  all.  A  revulsion  was  inevitable.  It  was  supposed  that  the  harm  was  due  to 
the  simple  fact  of  medical  reference.  Such  was  not  really  the  case.  The  sciences  were 
badly  taught,  not  merely  because  they  were  made  prematurely  and  excessively  con- 
scious of  medical  application, — though  such  had  indeed  been  the  case, — but  because 
the  teachers  lacked  abundant  scientific  knowledge  and  spirit.  Had  they  had  these, 
the  medical  reference  would  neither  have  dominated  nor  impoverished  their  presen- 
tation. Our  experience  then  furnishes  a  conclusive  argument  against  delegating  the 
teaching  function  to  essentially  unscientific  practising  physicians;  it  does  not  recom- 
mend the  isolation  of  the  laboratory  sciences,  locally  or  scientifically,  from  the  clin- 
ical work.  If  it  meant  that,  then  institutions  like  the  Johns  Hopkins  Medical 
School,  in  which  laboratories  and  hospital  are  compactly  organized  from  the  stand- 
point of  a  scientific  education  in  medicine,  would  labor  under  a  positive  disadvantage 
as  compared  with  schools  that,  by  reason  of  their  situation,  must  in  the  scientific 
years  forego  the  bedside  and  the  autopsy  altogether.  In  sober  truth,  four  years  are 
none  too  many  thoroughly  to  saturate  the  student  with  medical  enthusiasm  and 
to  give  him  the  physician's  standpoint;  nor  will  laboratory  and  clinical  ends  make 
a  genuine  whole  unless  they  have  throughout  a  speaking  acquaintance  with  each 
other. 

Physiology  and  pathology  belong,  then,  in  the  university,  because  there  is  much 
more  to  them  as  sciences  than  the  medical  school  has  time  for.  In  so  far,  however, 
as  they  figure  in  medical  education,  they  cannot  be  allowed  to  be  indifferent  to  this 
definite  function.  "There  must  be  an  outlying  division  of  workers  who  will  keep  the 

1 "  An  individual  mind  appropriates  those  new  points  of  view  and  those  fragments  of  knowledge  that 
find  in  the  mind  fitting  points  of  contact ;  but  others  that  fail  to  meet  with  suitable  receptors,  to  bor- 
row a  term  from  the  modern  theory  of  immunity,  remain  unattached  and  alien.  The  more  thoroughly 
we  can  utilize  existing  interests  and  established  relations,  the  more  likely  is  our  teaching  to  be  real 
training."  Letter  from  Professor  Edwin  O.  Jordan,  University  of  Chicago. 


60  MEDICAL  EDUCATION 

subject  in  touch  with  practical  medicine,  though  the  flower  of  the  army,  the  impe- 
rial guard,  are  busy  elsewhere."1  This  same  consideration  would  appear  conclusive 
as  to  the  wisdom  of  crediting  the  medical  student  with  such  subjects  when  pursued 
in  a  college  of  liberal  arts.  Physiology,  for  instance,  as  an  element  of  a  liberal  edu- 
cation, sweeps  the  whole  horizon  impartially,  interested  in  genetic  processes,  search- 
ing for  general  laws.  It  works  to  best  advantage  with  simple  forms, —  with  jellyfish  and 
cats  in  preference  to  man :  an  admirable  introduction  to  medical  physiology,  but  not 
really  the  same  thing.  It  does  not  follow,  therefore,  that  because  professional  studies 
are  now  freely  counted  toward  the  bachelor's  degree,  ordinary  college  work  in  physi- 
ology is  equally  satisfactory  to  the  medical  school.  The  academic  purpose  is  vague;  the 
professional  purpose,  distinct;  and  a  medical  education  is  more  than  the  sum  of  its 
constituent  courses  taken  separately  and  without  reference  to  their  ultimate  object.1 

So  much  for  the  point  of  view;  certain  general  considerations  affect  equally  in- 
struction in  all  these  laboratory  sciences.  The  medical  laboratories  must  be  manned, 
equipped,  and  organized  like  university  laboratories  devoted  to  non-medical  subjects. 
The  laboratory  staff  consists  necessarily  of  a  chief — the  professor  in  charge — with 
a  corps  of  paid  assistants,  cooperating  with  him  in  the  work  of  teaching,  busy  at 
other  times  with  their  problems,  as  he  is  with  his,  and  with  at  least  one  intelligent 
departmental  helper  (Diener)  who  will  relieve  the  staff  of  the  care  and  handling  of 
apparatus  and  material.  The  needs  of  pharmacology  are  in  these  respects  not  different 
from  those  of  physics;  and  the  pharmacologist  can  as  little  make  the  teaching  of 
pharmacology  a  side  issue  to  the  practice  of  medicine  or  the  conduct  of  a  drug  store 
as  the  physicist  can  subordinate  his  academic  duties  to  the  operation  of  a  trolley 
line.  Hardly  less  urgent  is  an  adequate  material  equipment:  class-rooms,  laboratories 
for  class  use,  private  rooms  adapted  to  the  independent  work  of  the  staff,  a  reference 
library  in  regular  receipt  of  important  publications,  and  proper  quarters  for  caring 
for  an  abundant  and  varied  supply  of  animals.3 

In  methods  of  instruction  there  is,  once  more,  nothing  to  distinguish  medical  from 
other  sciences.  Out-and-out  didactic  treatment  is  hopelessly  antequated;  it  belongs 

1 W.  H.  Howell :  "The  Present  Problems  of  Physiology,"  Congress  of  Arts  and  Sciencet,  vol.  v.  p.  434. 
More  concretely.  Professor  F.  S.  Lee  (Columbia  University),  in  discussing  the  medical  curriculum, 
wrote:  "Many  experiments  of  merely  technical  physiological  interest  should  be  omitted,  especially 
those  that  have  only  a  remote  connection  with  human  physiology.  .  . .  [In  physiological  chemistry] 
pathological  constituents  [of  tissues  and  secretions]  and  changes  should  be  touched  upon."  Professor 
Matthews  (University  of  Chicago)  took  the  opposite  position.  "As  soon  as  possible  these  sciences 
should  follow  the  example  of  physics,  botany,  and  chemistry  and  leave  the  medical  faculty  and  be 
regarded  as  subjects  prerequisite  to  the  study  of  medicine."  The  analogy  seems  hardly  valid;  physics 
and  chemistry  are,  from  the  standpoint  of  medicine,  of  merely  instrumental  value.  The  medical  sciences 
are  not  simply  instrumental ;  they  deal  with  the  actual  phenomena  and  material  which  the  physi- 
cian handles.  Professor  Lee  employs  pathological  cases  to  illustrate  and  enrich  his  course  in  pnysio- 
logy  at  Columbia.  The  contrast  between  normal  and  abnormal  deepens  the  student's  impression  of  both. 

2  The  same  problem  presents  itself  in  the  German  university.  See  Paulsen,  loc.  cit.,  pp.  411,  412. 

*  An  utterly  mistaken  notion  prevails  as  to  the  extent  to  which  animal  experimentation  is  practised 
in  this  country.  Only  a  very  small  minority  of  our  medical  schools  use  animals  at  all;  as  a  matter  of 
fact,  ordinary  medical  teaching  suffers  seriously  from  the  failure  to  employ  them. 


THE  LABORATORY  BRANCHES  61 

to  an  age  of  accepted  dogma  or  supposedly  complete  information,  when  the  professor 
"knew"  and  the  students  "learned."  The  lecture  indeed  continues  of  limited  use.  It 
may  be  employed  in  beginning  a  subject  to  orient  the  student,  to  indicate  relations, 
to  forecast  a  line  of  study  in  its  practical  bearings;  from  time  to  time,  too,  a  lecture 
may  profitably  sum  up,  interpret,  and  relate  results  experimentally  ascertained. 
Text-books,  atlases,  charts,  occupy  a  similar  position.  They  are  not,  in  the  first  place, 
a  substitute  for  sense  experience,  but  they  may  well  guide  and  fill  out  the  student's 
laboratory  findings.  In  general,  the  value  of  the  recitation  and  of  the  quiz  is  in  pro- 
portion to  their  concreteness  and  informality.  Outside  the  workshop  there  is  danger 
of  detachment  and  rote. 

The  curriculum  of  a  medical  school,  requiring  for  admission  at  least  a  competent 
knowledge  of  physics,  chemistry,  and  biology,  offers  in  the  first  two  years  systematic 
instruction  in  the  following  subjects: 

First  year:  anatomy,  including  histology  and  embryology;  physiology,  including 
bio-chemistry. 

Second  year:  pharmacology,  pathology,  bacteriology,  physical  diagnosis. 

A  brief  discussion  will  show  the  relations  of  these  subjects  to  each  other  and  to 
the  clinical  work  occupying  the  third  and  fourth  years. 

The  order  in  which  subjects  are  taken  up  is  largely  determined  by  considerations 
inherent  in  the  subjects  themselves.  Anatomy — the  study  of  the  architecture  of  the 
body — comes  logically  first.  It  is  indeed  the  oldest  of  laboratory  sciences,1  and  so  fun- 
damental in  medical  study  that  for  a  time  the  student  may  well  defer  all  other  sub- 
jects whatsoever.  For  several  centuries  it  was  taught  simply  by  professorial  demon- 
stration. During  the  first  half  of  the  nineteenth  century,  gross  dissection  by  the 
students  themselves  was  in  vogue.  The  subject,  long  almost  a  closed  book,  has  tre- 
mendously expanded  in  recent  years.  Embryology,  histology,  physiology,  and  patho- 
logy have  given  it  back  its  youth ;  it  is  once  more  a  green  and  flourishing  science.2 
The  anatomist  carries  a  steadily  increasing  load.  The  surgeon,  embarking  on  hitherto 
undreamed-of  ventures;  the  clinician,  guiding  himself  by  physical  indications  involv- 
ing the  most  delicate  structural  discrimination;  the  physiologist,  the  pharmacolo- 
gist, the  pathologist, — all  lean  upon  him.  With  an  eye  to  varied  uses,  the  student 
must  gain  a  picture  of  the  body  as  a  working  whole ;  of  its  parts,  taken  severally 
and  in  their  relations;  and  finally  of  the  microscopic  structure  of  tissues  and  organs. 
The  teacher  of  anatomy  may  take  one  of  two  roads.  He  may  attempt  to  forecast 
literally  the  special  requirements  of  each  of  the  above  branches,  confining  his  instruc- 

1 "  For  over  six  hur  dred  years  there  has  been  at  least  some  practical  instruction  in  anatomy,  and  for 
over  three  hundreu  years  there  have  existed  anatomical  laboratories  for  purposes  of  teaching  and  in- 
vestigation, although  only  those  constructed  during  the  present  century  (nineteenth)  meet  our  ideas 
of  what  an  anatomical  laboratory  should  be."  Welch:  The  Evolution  of  Modern  Scientific  Labora- 
tories: an  Address  delivered  at  the  Opening  of  the  William  Pepper  Laboratory,  University  of  Penn- 
sylvania, Dec.  4,  1895. 

2  For  an  extremely  readable  account  of  the  development  of  the  science  and  teaching  of  anatomy,  see 
"Anatomy  in  America,"  by  C.  R.  Bardeen,  Bulletin  of  the  University  of  Wisconsin,  no.  115. 


62  MEDICAL  EDUCATION 

tion  to  the  indispensably  useful  thus  arrived  at;  or  he  may  handle  his  subject  freely 
— not  unmindful  of  its  practical  value,  but  with  broad  scientific  background  and 
sympathy.  It  needs  no  argument  at  this  point  to  vindicate  the  latter  policy.  Dis- 
section has  therefore  ceased  to  be  synonymous  with  anatomy;  for  no  one  way  of 
looking  at  or  of  dealing  with  the  cadaver  will  enable  the  student  to  grasp  even 
its  gross  structure.  It  is  one  thing  to  take  the  body  to  pieces ;  it  is  something  else 
to  conceive  these  severed  and  dissociated  elements  in  stereoscopic  relation ;  and  it  is 
a  still  further  task  to  unravel  the  tissues  themselves :  hence,  on  the  macroscopic  side, 
the  prominence  now  given  to  reconstruction  through  drawing  and  modeling,  and 
the  close  study  of  charts  and  of  cross-sections,  of  models  and  of  special  preparations 
that  form  the  indispensable  teaching  museum.  Courses  in  histology  and  embryology, 
closely  correlated  with  gross  anatomy,  furnish  the  accompanying  microscopical  dis- 
cipline. Something  like  one-fifth  of  all  the  available  time  of  the  entire  medical 
curriculum1  is  commonly  absorbed  by  the  various  branches  constituting  a  modern 
department  of  anatomy.  How  much  of  this  may  be  profitably  spent  in  the  lecture- 
room  is  yet  under  discussion.  It  needs  perhaps  still  to  be  emphasized  that  description 
is  no  substitute  for  tactile  and  visual  experience,  and  that  such  experience,  if  intel- 
ligently controlled,  both  records  and  organizes  itself  with  surprisingly  little  formal 
revamping. 

Outside  of  anatomy,  the  laboratory  method  in  medicine  is  considerably  less  than 
a  century  old.  Its  rapid  spread  has  been  in  conservative  quarters  decried  as  a  fad; 
but  the  facts  suggest  a  nobler  view.  For  the  century  which  has  developed  medical 
laboratories  has  seen  the  death-rate  reduced  by  one-half  and  the  average  expectation 
of  life  increased  by  ten  or  twelve  years.*  Of  these  laboratories,  physiology  had  the 
first,  that  of  Purkinje,  at  Breslau,  established  in  1824.  In  general,  the  experimental 
physiologist  has  proceeded  upon  the  hypothesis  that  physiology  is  the  physics  and 
chemistry  of  living  matter.  He  employs  the  apparatus  and  procedure  of  the  physical 
laboratory  to  study  the  mechanical  properties  of  tissue  and  the  physical  conditions 
to  which  these  properties  respond.  The  mechanism  of  the  nervous  system,  the  circu- 
lation, respiration,  assimilation,  muscular  activity,  lend  themselves  more  or  less 
readily  to  description  and  interpretation  from  the  physical  point  of  view.  The  ap- 
paratus and  procedure  of  the  chemical  laboratory  have  been  brought  to  bear  in  the 
analysis  of  bodily  tissues,  fluids,  and  secretions,  and  in  the  experimental  reproduction 
of  digestive  and  other  processes.  Not  infrequently  the  subject  is  presented  in  two 
divisions,  the  former  called  physiology,  the  latter  physiological-  or  bio-chemistry. 
That  the  mechanical  standpoint  has  richly  justified  itself  is  indisputable;  neverthe- 
less, so  far  as  concerns  medical  education,  it  is  not  yet  ready  wholly  to  absorb  the 
functional  point  of  view.  An  unbridged  gap  exists.  Whether  the  physical  sciences 
will  ever  so  far  refine  their  procedure  as  altogether  to  resolve  function  in  mechanical 

1  Between  3600  and  4000  hours  of  instruction  make  up  the  entire  curriculum. 
•Welch:  Univerrity  of  Chicago  Rtcord,  vol.  xii.,  no.  S,  p.  79. 


THE  LABORATORY  BRANCHES  63 

terms,  it  is  needless  here  to  discuss.  Such  an  outcome  is  at  any  rate  more  distant  than 
the  early  investigators,  in  the  first  flush  of  their  splendid  successes,  supposed : 

"For  long  the  way  appears  which  seemed  so  short 
To  the  less  practised  eye  of  early  youth." 

Meanwhile,  whatever  its  limitations,  the  physiological  laboratory  is  of  immense  edu- 
cational importance  to  the  prospective  physician.  Physiology  is,  in  a  sense,  the  cen- 
tral discipline  of  the  medical  school.1  It  is  the  business  of  the  physician  to  restore 
normal  functioning:  normal  functioning  is  thus  his  starting-point  in  thought,  his  goal 
in  action.  The  physiological  laboratory  enables  the  beginner  to  observe  the  functions 
of  the  body  in  operation  and  to  ascertain  how  they  are  affected  by  varying  conditions, 
— a  wholesome  discipline  for  two  reasons:  it  banishes  from  his  mind  metaphysical 
principles,  such  as  vital  force,  depression,  etc. ;  it  tends,  in  exhibiting  the  infinite 
sublety  and  complexity  of  the  physiological  mechanism,  to  emphasize  normal  condi- 
tions rather  than  medication  as  ultimately  responsible  for  its  orderly  working.  The  stu- 
dent who  has  been  successfully  trained  to  regard  the  body  as  an  infinitely  complex 
machine  learns  to  doubt  his  capacity  to  mend  it  summarily.  It  is  true  he  lacks  time 
to  master  any  considerable  part  of  the  field  which  experimentation  has  covered  from 
this  point  of  view;  but  characteristic  and  pregnant  illustrations  at  least  insure  his 
sanity.  He  may  do  ever  so  little,  yet  for  that  little  he  cannot  take  anyone's  word. 
His  actual  contact  with  facts  puts  him  squarely  on  his  feet  and  cures  him  once  for 
all  of  mystical  and  empiric  vagaries. 

Anatomy  and  physiology  form  but  the  vestibule  of  medical  education.  They  teach 
the  normal  structure  of  the  body,  the  normal  function  of  the  parts,  fluids,  organs, 
and  the  conditions  under  which  they  operate.  The  next  step  carries  the  student  in 
medias  res;  he  begins  pharmacology,2 — the  experimental  study  of  the  response  of 
the  body  to  medication. 

The  science  got  its  problem  in  the  first  place  from  the  credulity  of  which  the  tra- 
ditional pharmacopoeia  is  the  encyclopedic  expression.  It  undertook  to  question  the 
complacency  and  vagueness  of  the  empiric.  How  far  was  his  reliance  upon  specific 
agents  justified?  If  at  all,  was  it  possible  to  ascertain  the  source  of  their  efficiency 
and  its  limits? 

Pharmacology  was  thus  originally  negative  and  critical.  It  rapidly  pruned  away 
exaggeration  and  superstition,  leaving,  however,  a  vigorous  growth  behind.  It  ascer- 
tained, for  example,  that  quinine  was  administered  in  vain  nine  times  out  of  ten ; 
but  that  in  the  single  condition  in  which  it  was  applicable — malaria — it  struck  at 
the  root  of  the  disease  by  actually  destroying  in  the  blood  the  obnoxious  parasite.  The 
limits  of  the  effectiveness  of  digitalis,  atropine,  strychnine,  have  been  discovered  and 
explained;  and  similarly,  the  utter  uselessness  of  dozens  of  concoctions  with  which 

lAbout  450  hours  of  instruction  are  devoted  to  it  on  the  average,  in  the  best  schools. 

8  The  first  laboratory  of  experimental  pharmacology  was  that  of  Rudolph  Buchheim  in  Dorpat,  1849. 


64  MEDICAL  EDUCATION 

the  digestive  capacity  of  the  race  has  long  been  taxed.  Intelligence  has  thus  been 
introduced  into  a  realm  for  ages  unguardedly  open  to  ignorance  and  recklessness. 

The  science  did  not  long  remain  merely  critical:  the  development  of  chemistry 
and  experimental  physiology  created  a  positive  opportunity.  Given,  in  a  word,  this 
or  that  condition, — a  disease,  a  symptom,  or  pain  itself, — cannot  an  agent  be  de- 
vised capable  of  combating  it?  Cocaine,  the  antipyretics,  the  various  glandular 
preparations,  and  serum  therapy  are  among  the  affirmative  replies  that  witness  the 
constructive  possibilities  of  pharmacodynamics.  The  strictly  experimental  science, 
thus  richly  rewarded,  has  reinforced  physiological  conceptions  independently  at  work 
in  the  effort  to  rationalize  materia  medica  and  therapeutics.  Instead  of  nai've  reli- 
ance upon  poly-pharmacy,  diseases  and  their  attendant  symptoms  have  now  been 
divided  into  some  half-dozen  provisional  classes,  subject  to  continuous  revision,  ac- 
cording to  the  method  of  attack  to  which  they  are  at  the  moment  most  accessible. 
There  are  those  that  drugs  actually  combat, — syphilis  and  malaria,  for  example; 
next,  the  self-limited  diseases,  in  the  course  of  which  therapeutic  measures  may  be 
used  to  avert  dangerous  symptomatic  consequences, — as  bathing  reduces  the  tem- 
perature in  typhoid,  as  chloroform  checks  convulsions  in  strychnine  poisoning,  as 
morphine  relieves  mere  pain.  There  are  those  in  which  the  body's  natural  methods 
of  defense  may  be  hastened  or  strengthened,  as  through  serum  therapy;  those  in 
which  our  only  reliance  thus  far  is  on  environment  or  suggestion;  and  finally,  those 
in  which  summary  relief  may  be  had  through  the  surgeon.  A  great  change,  this,  from 
indiscriminate  and  largely  ignorant  dosing!  The  body  diseased  is  indeed  like  a  city 
besieged.  No  single  form  of  military  manoeuvre  can  be  prescribed  as  a  sure  defense; 
now  a  sally  from  the  main  gate  discomfits  the  enemy;  again,  a  diversion  from  some 
unexpected  quarter;  sometimes  the  inhabitants  conserve  their  strength  in  the  hope 
of  wearing  the  enemy  out,  feeding  the  soldiers  at  the  expense  of  all  the  others;  and 
sometimes,  as  in  tuberculosis,  there  is  no  hope  except  by  actually  decamping,  leaving 
a  vacant  Moscow  to  a  cheated  foe. 

In  the  university,  pharmacology  has  critically  an  extensive,  creatively  an  appar- 
ently boundless,  opportunity.  The  medical  student  can  at  best  browse  the  field  here 
and  there.  But  as  was  found  to  be  the  case  with  experimental  physiology,  he  cannot 
forego  that  opportunity,  limited  though  it  be.  The  young  doctor's  therapeutic  en- 
vironment is  still  distinctly  unfavorable.  He  is  exposed  to  danger,  front  and  rear. 
The  traditions  of  the  profession  are  in  the  main  crudely  empiric;  they  embody  a 
"pop-gun  pharmacy,  hitting  now  the  malady  and  again  the  patient,  the  doctor 
himself  not  knowing  which.""1  Besides,  the  practitioner  is  subjected,  year  in,  year  out, 
to  the  steady  bombardment  of  the  unscrupulous  manufacturer,  persuasive  to  the  un- 
critical, on  the  principle  that  "what  I  tell  you  three  times  is  true."2  Against  bad 

1  Osier,  Aequanimitcu,  p.  127. 

8  "On  a  basis  of  5000  prescriptions  examined,  47  per  cent  are  for  proprietary  medicines."  M.  G.  Mot- 
ter,  in  Bull.  Amer.  Acad.  Med.,  vol.  ix.,  no.  1. 


THE  LABORATORY  BRANCHES  65 

example  and  persistent  asseveration,  only  precise  scientific  concepts  and  a  critical 
appreciation  of  the  nature  and  limits  of  actual  demonstration  can  protect  the  young 
physician.  The  laity  has  in  this  matter  more  to  fear  from  credulous  doctors  than 
from  advertisements  themselves:  for  a  nostrum  containing  dangerous  drugs  is  doubly 
dangerous  if  introduced  into  the  household  by  the  prescription  of  a  physician  who 
knows  nothing  of  its  composition  and  is  misled  as  to  its  effect.1  Experimental  physi- 
ology and  pharmacology  must  train  the  student  both  to  doubt  unwarranted  claims 
and  to  be  open  to  really  authoritative  suggestion:  for  it  is  equally  important  to 
reject  humbug  and  to  accept  truth.  Fortunately,  even  a  brief  concrete  experience 
may  teach  one  to  be  wary  in  weighing  evidence. 

The  course  in  pharmacology  need  include,  therefore,  actual  experimental  determina- 
tion by  the  student  himself  of  the  effect  on  animals  of  a  relatively  small  number  of 
carefully  selected  agents;  demonstration  of  others  by  the  instructor;  and  a  critical 
survey  of  the  rest  by  means  of  lectures  and  recitations.2  Materia  medica,  now  much 
shrunken,  need  concern  itself  only  with  the  pharmaceutical  side,  aiming  to  familiarize 
the  student  with  drugs  of  proved  power  and  the  most  agreeable  and  effective  forms 
in  which  these  may  be  administered.  Therapeutics  subsequently  adds  to  these  agents 
whatever  other  resources  the  clinician  has  accumulated, — baths,  electricity,  massage, 
psychic  suggestion,  dietetics,  etc., — approaching  the  subject  from  the  standpoint  of 
disease,  as  opposed  to  the  pharmacological  approach  from  the  standpoint  of  the  drug 
itself. 

The  last  division  of  the  medical  sciences — and  the  most  extensive — includes 
pathology  and  bacteriology.  The  three  subdivisions  of  pathology  are  symmetrical 
with  anatomy,  physiology,  and  physiological  chemistry.  To  the  first  corresponds 
pathological  anatomy;  to  the  second,  pathological  physiology;  to  the  third,  chemical 
pathology. 

In  its  modern  form  the  study  began  on  a  comprehensive  basis  when  Virchow, 
called  from  Wiirzburg,  established  the  first  pathological  institute  in  Berlin  in  1856. 
His  plans  went  far  beyond  the  gross  morbid  anatomy  then  current.  He  conceived 
pathology  not  only  as  a  descriptive  but  as  an  experimental  science,  whose  laws  are 
the  laws  of  general  biology.  The  pathological  is  not,  in  this  view,  an  anarchic,  extra- 
legal  freak ;  it  is  the  product  of  agencies  and  forces,  operating  on  regular  and  inev- 
itable lines.  The  problem  of  the  pathologist  is  through  observation  and  experiment 
to  get  the  key  to  the  pathological  process,  in  order  that  he  may  understand  its  origin 
and  significance,  and,  if  necessary,  avert  or  control  it.  The  pathological  is  abnormal 
from  the  standpoint,  not  of  biological  law,  but  of  the  human  interests  that  it  some- 
times thwarts — sometimes,  only;  for  not  infrequently  it  is  a  beneficent,  compensa- 

1  See  The  Propaganda  for  Reform  in  Proprietary  Medicines,  published  by  the  American  Medical 
Association,  Chicago,  111. 

2  On  the  average,  about  150  hours  are  devoted  to  instruction  in  pharmacology;  something  more  than 
half  of  these  can  be  given  to  the  laboratory,  the  remainder  to  recitations. 


66  MEDICAL  EDUCATION 

tory  adjustment,  actually  favorable  to  the  individual.  Experimental  pathology  has 
developed  along  both  biological  and  chemical  lines:  the  former,  accentuating  the 
life-history  of  the  abnormal  growth,  the  latter,  endeavoring  to  trace  back  the  changes 
observed  to  the  chemical  activities  involved  in  the  life-process.  Somewhat  recently, 
a  shifting  of  emphasis  has  made  the  physiological  point  of  view  more  prominent, — 
a  wholesome  development,  medically  speaking.  The  physician  is  constantly  in  con- 
tact with  disease  processes  that  he  is  unable  to  correlate  with  the  accompanying 
structural  modifications.  Occasionally  the  surgeon  throws  a  stream  of  light  upon  such 
a  situation ;  too  often,  all  is  dark  until  the  autopsy  reveals  the  truth.  Pathological 
physiology  aims  to  study  structural  change  from  the  standpoint  of  function.  It  asks 
primarily  not  what  is  the  history  of  the  structural  modification  itself,  but  what  are 
its  progressive  consequences  to  the  functional  routine  of  the  organism.  It  reproduces 
disease  experimentally,  interrupting  its  course  at  significant  stages,  in  order,  having 
observed  the  functional  disturbance,  to  ascertain  exactly  the  structural  readjustment 
that  corresponds.  "In  animals,1"  says  Professor  Hektoen,  "  the  course  of  disease  may 
be  cut  short  at  any  time  for  the  purpose  of  investigation.  The  disease  may  be  studied 
in  all  its  phases.  Comparative  pathology  became  the  refuge  of  the  investigator, 
blocked  by  the  necessary  restrictions  governing  the  study  of  human  diseases.  The 
great  influence  of  the  comparative  method  is  shown  in  the  relatively  advanced  state 
of  our  knowledge  in  regard  to  human  diseases  readily  communicable  to  animals,  as 
compared  with  our  ignorance  in  regard  to  other  human  diseases  which,  so  far  as  we 
know,  are  not  transferable  to  animals."1  For  the  prospective  physician  the  value  of 
such  a  course  depends,  of  course,  on  the  opportunity  to  compare  the  laboratory  find- 
ings with  the  symptoms  shown  by  patients  in  the  hospital  wards. 

In  general,  the  effective  teaching  of  pathology  is  dependent  on  ease  and  frequency 
of  access  to  the  autopsy-room.  It  would  be  difficult  just  now  to  over-emphasize  that 
point.  We  shall  soon  see  that  the  post-mortem  is  in  this  country  relatively  rare  and 
precarious;  that  not  infrequently  pathological  courses  are  organized  and  given  whose 
illustrative  material  is  limited  to  models,  to  a  small  number  of  preserved  specimens, 
or  even  to  bits  of  material  already  cut  into  microscopic  sections  or  just  lacking  that 
last  touch.  Such  instruction  may  do  justice  to  the  subject  on  the  histological  side, 
but  it  leaves  much  to  the  already  overburdened  third  and  fourth  years.  And  it  is 
surely  a  serious  disadvantage  to  the  teacher  of  pathology  to  find  himself  year  after 
year  teaching  the  subject  without  access  to  the  post-mortem  room. 

Specimens  alone — whether  gross  or  microscopic — are  inadequate  for  several  rea- 
sons. In  the  first  place,  gross  fresh  specimens  are  too  perishable :  they  change  quickly 
after  removal  from  the  body  and  in  consequence  of  handling  during  transportation ; 
refrigeration  avoids  softening  and  putrefaction  only  at  the  cost  of  destroying  the 
blood,  —  a  most  important  link  in  the  chain.  More  important  still,  however,  is  the 
consideration  that  disease  is  not  an  affair  of  a  single  organ  or  tissue,  still  less,  of  a 
1  Conyrtu  of  Artt  and  Science*,  voL  vi.  pp.  112,  113  (slightly  abridged). 


THE  LABORATORY  BRANCHES  67 

microscopic  portion  of  such  organ  or  tissue.  Even  an  acute  disease — pneumonia, 
diphtheria — involves  the  body  as  a  whole;  chronic  defects — such  as  heart  lesion  or 
cancer — affect  the  organism  likewise  in  its  entire  extent.  The  pathologist,  then,  seek- 
ing to  convey  to  the  student  an  objective  conception  of  the  nature  and  effects  of 
disease  as  a  process,  needs  the  entire  body  in  order  to  do  so.  Pathology  is  taught  for 
that  purpose;  it  fails  of  its  object  just  so  far  as  the  lack  of  autopsies  makes  it  im- 
possible. Cancer,  for  example,  is  not  a  local  disturbance  involving  this  or  that  organ. 
The  student  who  is  expected  to  grasp  its  character  cannot  do  so  if  all  he  does  is  to 
see  a  cross-section  put  up  in  gelatine,  or  to  handle  a  papier-mache  reproduction,  or 
to  observe  the  cell  changes  on  a  small  slide.  These  things  are  well  enough  as  far  as 
they  go,  but  they  go  only  a  short  distance.  The  cancerous  process  is  complicated  and 
extensive.  Other  organs,  far  from  the  original  site  of  the  disease,  are  involved ;  nay, 
the  original  site  itself  may  be  in  question.  The  vastness  of  the  involvements,  the  re- 
lationships of  affected  locations  to  each  other,  the  response  of  the  bodily  mechanism 
fighting  to  achieve  a  readjustment — only  the  autopsy  can  disclose  these;  and  with- 
out them,  the  student  cannot  attain  an  intelligent  conception  of  the  subject  he  is 
studying. 

Pathology's  greatest  contribution  to  the  comprehension  and  mastery  of  disease 
has  been  by  way  of  illuminating  its  causation, — or  etiology.  The  student  who  is  to 
comprehend  the  significance  of  disease  must  not  only  make  the  inventory  of  results 
disclosed  by  the  post-mortem :  he  should  be  allowed  to  observe  the  process  from  the 
very  start.  To  this  end,  a  demonstrative  course,  using  living  animals,  must  be  pro- 
vided. Tuberculosis,  for  example,  should  be  exhibited  through  the  inoculation  of  a 
few  guinea  pigs  with  different  varieties  of  the  tubercle  bacilli,  showing  the  various 
ways  in  which  the  bacilli  enter  and  are  distributed,  and  the  variety  of  lesions  that 
they  produce. 

We  thus  cross  the  threshold  of  still  another  science,  bacteriology,  developed  in 
late  years  in  close  sympathy  with  pathology.  It  presents  the  same  two  sides, — bio- 
logical and  chemical;  the  former  investigating  the  life-history  of  the  microscopic 
organism,  the  latter  isolating  and  resolving  its,  toxic  or  other  products.  The  search 
of  the  pathologist  for  the  original  causation  of  abnormal  structural  change  has  been 
immensely  facilitated  by  the  bacteriologist  He  can  now  account  for  as  well  as  de- 
scribe the  ravaged  tissues  that  mark  the  path  of  a  diphtheritic,  typhoid,  or  tuber- 
culous infection.  Out  of  the  life-history  of  the  parasites  in  question  has  sprung  the 
serum  therapy,  which  has  already  stripped  tetanus,  diphtheria,  and  meningitis  of 
much  of  their  horror. 

Perhaps  even  more  important  than  its  services  to  curative,  have  been  the  sugges- 
tions of  bacteriology  to  preventive,  medicine.  It  is  hardly  too  much  to  say  that  mo- 
dern hygiene,  largely  the  outcome  of  bacteriology,  has  elevated  the  physician  from 
a  mainly  personal  to  a  mainly  social  status.  Directly  or  indirectly,  disease  has  been 
found  to  depend  largely  on  unpropitious  environment.  A  bad  water-supply,  defective 


68  MEDICAL  EDUCATION 

drainage,  impure  food,  unfavorable  occupational  surroundings, — matters,  all  of  them, 
for  social  regulation, — at  once  harbor  our  parasitic  enemies  and  reduce  our  powers 
of  resisting  them.  To  the  intelligent  and  conscientious  physician,  a  typhoid  patient 
is  not  only  a  case,  but  a  warning :  his  office  it  is  equally  to  heal  the  sick  and  to  pro- 
tect the  well.  The  public  health  laboratory  belongs,  then,  under  the  wing  of  the 
medical  school.  It  is  the  clearing-house  into  which  data  from  an  entire  state  should 
pour.  Tax-supported  institutions  are  most  favorably  circumstanced  in  this  respect. 
The  material  which  they  readily  accumulate  is  at  once  a  basis  for  teaching,  for  in- 
vestigation, and  for  practical  sanitation.  Thus  the  laboratory  sciences  all  culminate 
and  come  together  in  the  hygienic  laboratory;  out  of  which  emerges  the  young 
physician,  equipped  with  sound  views  as  to  the  nature,  causation,  spread,  prevention, 
and  cure  of  disease,  and  with  an  exalted  conception  of  his  own  duty  to  promote 
social  conditions  that  conduce  to  physical  well-being. 

From  the  standpoint  of  medical  education,  a  detached  academic  or  scientific  treat- 
ment of  pathology  and  bacteriology  would  sacrifice  needlessly  much  of  their  value. 
Both  subjects  are,  indeed,  full-grown  biological  sciences, — university  subjects,  capa- 
ble of  cultivation  only  in  special  laboratories,  closely  affiliated  with  general  biology 
and  chemistry.  But  the  medical  student  in  the  brief  five  hundred  hours  which  he 
can  at  most  secure  for  them  gains  the  clearest  insight  into  their  philosophy  and 
their  bearing  by  following  out  their  principles  mainly  in  the  small  group  of  phe- 
nomena illustrated  in  human  disease.  Experimental  pathology  concerns  him  because 
it  enables  him  later  to  conceive  his  clinical  problems  intelligently.  From  an  early 
hour  in  his  pathological  work,  the  student  may  then  begin  in  the  autopsy-room  to 
saturate  himself  with  the  clinical  spirit.  This  is  not  to  be  confused  with  the  prema- 
ture "cutting"  or  the  impatient  "prescribing"  to  which  the  old-fashioned  medical 
student  was  addicted.  "Cutting"  and  "prescribing"  may  still  be  two  years  distant; 
but  meanwhile  it  is  both  possible  and  "important  to  keep  ever  before  the  student 
the  part  which  the  work  he  is  doing  plays  in  leading  to  a  more  complete  compre- 
hension of  disease."1 

One  closes  a  brief  review  of  the  medical  sciences  with  a  feeling  akin  to  dismay. 
So  much  remains  to  find  out,- so  much  is  already  known, — how  futile  to  orient  the 
student  from  either  standpoint!  Practically,  however,  there  is  no  ground  for  despair. 
Enough  can  be  achieved  to  give  him  precise  conceptions  in  each  of  the  realms  touched 
upon;  and  the  actual  value  of  these  conceptions  and  of  the  habits  grounded  on  them 
depends  less  on  the  extent  of  his  acquisitions  than  on  his  sense  of  their  reality.8 
Didactic  information,  like  mere  hearsay,  leaves  this  sense  pale  and  ineffective;  a  first- 

1  Report  of  Committee  on  Pathology,  Council  on  Education,  Araer.  Med.  Assn.,  Bulletin  of  Arner. 
Jted.  Aim.,  Sept  15,  1909,  p.  47. 

*  That  method  rather  than  any  particular  content  is  the  very  essence  of  scientific  discipline  is  admi- 
rably pointed  out  by  Professor  Dewey  in  his  address  "Science  as  Subject-matter  and  as  Method," 
Science,  xxxi.,  no.  787,  p.  122.  "Science  has  been  taught  too  much  as  an  accumulation  of  ready-made 
material,  with  which  students  are  to  be  made  familiar,  not  enough  as  a  method  of  thinking,  an 
attitude  of  mind,  after  the  pattern  of  which  mental  habits  are  to  be  transformed." 


THE  LABORATORY  BRANCHES  69 

hand  experience,  be  it  ever  so  fragmentary,  renders  it  vivid.  After  a  strenuous  labo- 
ratory discipline,  the  student  will  still  be  ignorant  of  many  things,  but  at  any  rate 
he  will  respect  facts :  he  will  have  learned  how  to  obtain  them  and  what  to  do  with 
them  when  he  has  them. 

NOTE 

For  the  details  of  a  course  of  study,  framed  on  the  lines  above  described,  the  reader 
is  referred  to  the  following: 

A.  GENERAL, 

1.  Report  of  Curriculum  Committee,  Council  on  Education,  American  Medical  Asso- 

ciation, Bulletin  of  the  Amer.  Med.  Asm.,  September,  1909. 

2.  What  Constitutes  a  Medical  Curriculum  f  Issued  by  Association  of  American  Med- 

ical Colleges. 

3.  COLWELL,  N.  P.:  In  Bulletin  of  American  Academy  of  Medicine,  vol.  x.,  no.  3. 

4.  BILLKOTH,  T. :  Ueber  Lehren  und  Lernen  in  Medicin. 

5.  BICKEL,  ADOLF:  Wie  Studiert  man  Medizinf  (Stuttgart,  1906). 

B.  SPECIAL  SUBJECTS 

1.  Anatomy. 

BARKER,  L.  F.,  and  BARDEEN,  C.  R. :  Outline  of  Course  in  Normal  Histology  and 

Microscopic  Anatomy,  Johns  Hopkins  Hospital  Bulletin,  vol.  xii.,  nos.  62,  63. 
BARKER,  L.  F.,  and  KYES,  P. :  On  Teaching  of  Normal  Anatomy  of  Central  Nervous 

System  to  Large  Classes  of  Medical  Students,  Proc.  Assn.  Amer.  Anat.,  1900. 
BARKER,  L.  F. :  Study  of  Anatomy,  Journal  Amer.  Med.  Assn.,  March,  1901. 
DWIGHT,  T. :  Methods  of  Teaching  Anatomy  at  Harvard  Medical  School,  Boston 

Med.  and  Surg.  Journal,  vol.  cxxiv.  pp.  457-77. 

HUNTINGTON,  G.  S. :  The  Teaching  of  Anatomy,  Columbia  University  Bulletin,  1898. 
KEILLER,  W. :  On  Preservation  of  Subjects  for  Dissection,  etc.,  Amer.  Jour.  Anat., 

1902-3,  vol.  ii. 

McMuRRicK,  J.  P. :  Conservatism  in  Anatomy,  Anat.  Record,  vol.  iii.,  no.  1. 
MALL,  F.  P. :  The  Anatomical  Course  and  Laboratory  at  Johns  Hopkins  University, 

Johns  Hopkins  Hospital  Bulletin,  vol.  vii.,  nos.  62,  63. 
MALL,  F.  P.:  On  Teaching  Anatomy,  etc.,  Ibid.,  vol.  xvi.,  no.  167. 
MALL,  F.  P. :  On  the  Teaching  of  Anatomy,  Anat.  Record,  vol.  ii.,  no.  8. 
MOODY,  R.  C. :  On  the  Use  of  Clay  Modelling  in  the  Study  of  Osteology,  Johns  Hop- 

Jcins  Hospital  Bulletin,  1903,  vol.  xiv. 

2.  Physiology. 

PORTER,  W.  T. :  The  Teaching  of  Physiology  in  Medical  Schools,  Boston  Med.  and 
Surg.  Journal,  December  29,  1898. 


70  MEDICAL  EDUCATION 

CHITTENDEN,  R.  H. :  The  Importance  of  Physiological  Chemistry  as  a  Part  of  Medi- 
cal Education,  N.  Y.  Med.  Journal,  September  30,  1898. 

BOWDITCH,  H.  P. :  The  Study  of  Physiology,  Univ.  Pa.  Med.  Bulletin,  June,  1904. 

HOWELL,  W.  H. :  Instruction  in  Physiology  in  Med.  Schools,  The  Michigan  Alumnus, 
January,  1900. 

LEE,  F.  S. :  Physiology  (Series :  Lectures  on  Science,  Philosophy  and  Art,  Columbia 
Univ.  Press,  1909). 

5.  Pharmacology. 

ABEL,  J.  J. :  On  the  Teaching  of  Pharmacology,  Materia  Medica,  and  Therapeutics, 
Phila.  Med.  Jour.,  September  1,  1900. 

SOLLMAN,  T. :  The  Teaching  of  Therapeutics  and  Pharmacology  from  the  Experi- 
mental Standpoint,  Jour.  Amer.  Med.  Assn.,  September  6,  1902. 

4.  Pathology  and  Bacteriology. 

ADAMI,  J.  G. :  On  the  Teaching  of  Pathology,  Phua.  Med.  Jour.,  1900,  pp.  399-402. 

DELEPINE,  A.  S. :  On  the  Place  of  Pathology  in  Medical  Education,  Brit.  Med.  Jour., 
1896,  vol.  ii. 

JORDAN,  E.  O. :  Place  of  Pathology  in  the  University,  Jour.  Amer.  Med.  Assn.,  1907, 
vol.  xlviii.  p.  917. 

BARKER,  L.  F. :  On  Methods  of  Studying  Pathology,  Amer.  Text-Book  of  Path.,  Phila- 
delphia, 1901. 

5.  Hygiene. 

DITMAN,  N.  E. :  Education  and  its  Economic  Value  in  the  Field  of  Preventive  Med- 
icine, Columbia  University  Quarterly,  vol.  x.,  supplement  to  no.  3,  June,  1908. 

WINSLOW,  C.  E.  A. :  Teaching  of  Biology  and  Sanitary  Science  in  the  Massachusetts 
Institute  of  Technology,  Tech.  Quarterly,  vol.  xix.,  no.  4,  December,  1906. 

WESBROOK,  F.  F.:  The  Laboratory  in  Public  Health  Work,  Twelfth  Biennial  Report 
of  Iowa  State  Board  of  Health. 

WESBROOK,  F.  F. :  The  Public  Health  Laboratory,  Jour.  Amer.  Med.,  vol.  xi.,  no.  9. 


CHAPTER  V 

THE  COURSE  OF  STUDY:  THE  LABORATORY  BRANCHES 

(B)  FIRST  AND  SECOND  YEAKS  (CONTINUED) 

WITH  the  preceding  characterization,  the  schools  included  in  our  first  division l  on 
the  whole  agree.  They  are  all  organic  parts  of  full-fledged  universities ;  their  medical 
courses  are  as  a  rule  constructed  upon  the  basis  of  adequate  pre-medical  scientific 
training.  In  general,  the  laboratories  of  institutions  upon  a  college  basis  reflect  uni- 
versity ideals  in  equipment,  management,  and  appearance.2  As  a  rule  these  institu- 
tions have  at  least  four  separate  laboratories,  for  anatomy,  physiology  and  bio-chem- 
istry, pharmacology,  pathology  and  bacteriology.  As  their  resources  have  grown,  the 
departments  have  tended  to  increase  by  subdivision :  histology,  physiological  chem- 
istry, clinical  pathology,  bacteriology,  attain  departmental  stature.  Hygiene  is  es- 
pecially prominent  at  the  state  universities,  where  effective  departments  of  public 
health  bring  the  laboratories  of  pathology  and  bacteriology  into  fruitful  relation 
with  local  authorities  and  the  local  profession  throughout  the  state ;  and  endowed 
schools  are  making  determined  efforts  to  develop  departments  of  preventive  medi- 
cine. In  some  cases  abundant,  in  several  others  increasing,  facilities  are  offered  in  all 
branches  for  both  teaching  and  research;  and  teaching  and  research  permeate  each 
other.  The  various  departments,  in  intimate  communication  with  each  other  and  with 
the  general  science  work  of  the  institution,  are  officered  each  by  its  own  full-time 
professor,  in  most  instances  with  a  more  or  less  satisfactory  corps  of  paid  assistants. 
Within  these  active  hives  of  scientific  interest  a  thoroughly  charming  relation  pre- 
vails: a  vigorous,  stimulating,  and  appreciative  chief,  on  the  one  hand,  enjoying  the 
cooperation  of  enthusiastic  young  disciples  on  the  other.  It  is  difficult  to  realize  that  so 
substantial  an  organization  is  so  recent, — hardly  more  than  a  half-century  old  in  Ger- 
many, less  than  twenty  years  old  in  America.  In  this  brief  period  the  earlier  subordi- 
nates have  themselves  become  departmental  heads  in  their  own  schools,  or  have  gone 
forth  to  found  or  to  reconstruct  distant  institutions.  Laboratories  have  increased  in 
number  so  rapidly  that  the  rewards  of  early  promise  or  of  early  performance  have 
been  alike  great  and  prompt.  It  is  unlikely  that  this  pace  will  permanently  keep  up. 
In  anatomy  and  physiology  it  occasionally  occurs  that  the  departmental  head  is 
not  himself  a  graduate  in  medicine.3  This  innovation  arises  out  of  a  dual  motive :  it 

1  i.  e. ,  those  requiring  for  entrance  two  or  more  years  of  college  work ;  a  list  of  them  is  given  on  page  28. 

a  A  few  of  these,  formerly  on  a  lower  basis,  have  elevated  their  entrance  requirements,  while  leav- 
ing facilities  as  they  were.  Several  schools  are  pledged  to  higher  entrance  requirements,  though  quite 
unable  to  improve  their  facilities.  Indeed,  as  higher  standards  mean  fewer  students  and  reduced  in- 
come, their  facilities  may  suffer  deterioration. 

3  Occasionally  the  dean  of  a  medical  school  is  a  non-medical  man.  In  such  cases  it  is  extremely  im- 
portant that  he  be  in  close  sympathy  with  the  clinical  side  and  well  acquainted  with  modern  devel- 
opments in  clinical  teaching.  Even  more  dangerous  is  the  expedient  of  making  a  professor  in  the 
academic  department  dean  of  the  medical  department. 


72  MEDICAL  EDUCATION 

represents  a  reaction  from  the  superficial  methods  of  the  practitioner  professor,  as 
well  as  a  realization  of  the  essential  continuity  of  medical  with  biological  science.  The 
non-medical  professor  is  not  necessarily  indifferent  to  explicit  medical  reference;  his 
department  need  not  lack  sympathy  with  medicine  merely  because  he  has  no  M.D. 
degree;  and  his  disinterested  attitude  is  in  any  event  indispensable.  But  the  experi- 
ment is  not  free  from  danger,  and  its  outcome  will  be  watched  with  interest.  Mean- 
while, there  is  no  question  that  these  posts  cannot  be  satisfactorily  filled  by  active 
physicians.  The  practitioner  usually  lacks  impartial  and  eager  scientific  spirit;  he 
can  at  best  give  set  hours  to  teaching,  and  these  are  not  infrequently  interrupted 
by  a  patient's  superior  claim;  of  course  he  has  little  or  no  time  and  rarely  any  zest 
for  research.  Western  Reserve  and  the  New  York  City  department  of  Cornell,  alone 
of  schools  of  this  rank,  continue  an  active  surgeon  in  the  chair  of  anatomy. 

Of  the  twenty-five  institutions  either  now,  or  by  the  fall  of  1910  to  be,  on  the  two- 
year  college  basis,  or  more,  fourteen1  offer  the  entire  four-year  course  in  one  organized 
institution ;  five8  are  divided,  offering  the  laboratory  branches  in  one  place  and  the 
clinical  branches,  more  or  less  independently  organized,  in  another,  sometimes  close 
by,  at  other  times  widely  separated;  six3  are  half-schools,  offering  only  the  work 
of  the  first  and  second  years.  The  complete  school  in  touch  with  the  rest  of  the 
university  represents  the  normal  and  correct  form.  The  study  of  medicine  must 
center  around  disease  in  concrete,  individual  forms.  The  ease  with  which  the  clinics 
and  the  laboratories  may  there  illuminate  each  other  is  an  incontestable  advantage 
to  both.  It  is  difficult  to  imagine  effective  teaching  of  pathology,  for  example,  under 
conditions  where  the  operating-room,  the  medical  clinic,  and  the  autopsy  do  not 
constantly  contribute  specimens  and  propound  queries  to  the  laboratory;  and  assuredly 
the  teaching  of  medicine  and  surgery  cannot  proceed  intelligently  without  constant 
intercourse  with  the  laboratories.  Any  disintegration  of  hospitals  and  laboratories  is 
harmful  to  both,  —  and  to  the  student,  in  shaping  whom  they  must  cooperate.  So 
important  is  organic  wholeness  that  the  remote  department,  if  entire,  is  from 
all  points  of  view  preferable  to  division.  The  initial  difficulty — that  of  sharing 
the  university  ideals — may  be  met  by  liberal  provision  for  intercourse  with  the 
academic  body  and  by  redoubled  efforts  to  maintain  creative  activity,  as  Cornell, 
for  example,  has  done  at  New  York.  Fortunately,  our  needs  in  respect  to  medical 

1  Johns  Hopkins,  Harvard,  Western  Reserve,  Minnesota,  Cornell  (New  York  City  department),  Yale, 
Michigan,  Indiana  (Indianapolis  department),  Iowa,  Pennsylvania,  Syracuse,  Columbia,  Dartmouth, 
Colorado.  Of  these,  two  are  not  located  in  the  same  town  as  the  university, — Cornell  (New  York 
City),  Indiana  (Indianapolis). 

'Rush  Medical  College  (of  which,  though  both  parts  are  in  Chicago,  the  first  two  years  belong  to  the 
University  of  Chicago,  and  the  last  two,  given  elsewhere  in  the  city,  are  only  affiliated  with  it),  Cali- 
fornia (first  and  second  years  at  Berkeley,  third  and  fourth  at  San  Francisco  and  Los  Angeles), 
Nebraska  (first  and  second  years  at  Lincoln,  third  and  fourth  at  Omaha),  Kansas  (first  and  second 
years  at  Lawrence,  third  and  fourth  at  Rosedale),  Stanford  (first  and  second  years  at  Palo  Alto,  third 
and  fourth  at  San  Francisco). 

•Wisconsin,  Missouri,  South  Dakota,  North  Dakota,  Utah,  Wake  Forest.  Cornell  repeats  the  first 
year  at  Ithaca;  Indiana  duplicates  the  first  and  second  years  at  Bloomington. 


THE  LABORATORY  BRANCHES  73 

schools  can  be  met  without  considerable  resort  to  either  the  divided  or  the  remote 
department.1 

The  divided  school  begins  by  inheriting  a  serious  problem.  Its  laboratory  end, 
situated  at  the  university,  has  been  recently  constituted  of  modern  men;  the  clinical 
end,  situated  in  a  city  at  some  distance,  is  usually  what  is  left  of  the  old-fashioned 
school  which  the  university  adopted  in  taking  on  its  medical  department.2  In  such 
cases,  there  are  practically  two  schools  with  a  formal  connection;  such  is  essentially 
the  situation  in  California,  Kansas,  and  Nebraska.  In  course  of  time  these  clinical 
faculties  will  be  reconstituted  of  men  of  more  modern  stamp.  But  the  separation  of 
the  clinical  branch,  with  the  increasing  absorption  of  the  teachers  in  practice,  in- 
volves constant  danger  of  fresh  alienation.  The  clinical  professor  of  the  university 
is  very  apt  to  be  a  busy  physician;  and  if  so,  pedagogical  and  scientific  ideals  are  all 
the  more  easily  crowded  into  a  narrow  corner,  when  he  does  not  breathe  the  bracing 
atmosphere  of  adjacent  laboratories.  In  time,  a  more  exacting  pedagogical  code  and 
increased  sensitiveness  to  real  scientific  distinction  may  to  some  extent  correct  the  ten- 
dency. Meanwhile,  these  institutions,  so  long  as  they  continue,  require  much  more  vig- 
orous administrative  supervision  than  they  have  anywhere  received.  A  dean,  moving 
freely  between  the  two  branches,  and  frequent  opportunities  for  social  and  scientific 
intercourse  between  scientific  and  clinical  faculties,  may  throw  a  more  or  less  unsteady 
bridge  across  the  gap.  But  there  is  little  reason  to  believe  that  the  divided  school  will 
ever  function  as  an  organic  whole,  though  it  may  be  tolerable  as  a  halfway  stage  on  the 
road  from  the  proprietary  school  to  the  complete  university  department.  "I  cannot 
help  wondering,"  said  President  Pritchett,3  "how  it  would  affect  the  pedagogic  and 
professional  ideals  of  an  engineering  school  if  its  first  two  years  were  given  in  one 
place  and  the  last  two  years  in  a  place  two  hundred  miles  away.  My  impression  is 
that  there  would  be  two  separate  schools  with  very  little  more  reaction,  the  one  upon 
the  other,  than  exists  between  any  other  two  schools  so  located."  Thus  far  the  diffi- 
culty seems  hardly  to  have  been  suspected:  the  dean  of  Nebraska  at  Lincoln  is  a 
busy  professor  who  has  no  real  hold  on  the  clinical  men  at  Omaha;  the  dean  of  Cali- 
fornia is  superintendent  of  the  hospital  in  San  Francisco,  with  no  real  control  of  what 
goes  on  at  Berkeley,  and  surely  without  any  possible  control  over  the  second  clinical 
department  at  Los  Angeles ;  Kansas  practically  accepts  the  split  by  setting  up  a  dean 
at  each  of  the  two  ends,  though  they  are  only  an  hour  and  a  half  apart;  Mississippi, 
with  even  better  reason,  does  the  same,  for  the  journey  from  Oxford  to  Vicksburg, 
not  great  when  measured  in  miles,  takes  the  better  part  of  a  day  even  if  one  is  lucky 
enough  to  make  the  necessary  railroad  connections. 

The  problem  of  the  half-school  is  different.  The  two-year  school  originated  in 

1  See  chapter  ix. 

2  In  a  measure,  also  still  true  of  some  of  the  complete  schools;  but  the  constant  contact  of  laboratory 
and  clinical  men  tends  gradually  to  bring  the  edges  together. 

8  Address  :  "The  Obligations  of  the  University  to  Medical  Education,"  before  Council  on  Education, 
American  Medical  Association,  Feb.  28,  1910  (Journal  A.  M.  A.,  vol.  liv.  p.  1109). 


74  MEDICAL  EDUCATION 

institutional  expediency;  but  it  may  prove  of  actual  pedagogical  importance.  When 
Columbia  and  Michigan  arranged  that  the  four  years  of  the  A.B.  course  might  con- 
tain two  years  of  the  M.D.  course,  institutions  lacking  medical  departments  were 
impelled  to  offer  just  enough  of  the  medical  curriculum  to  meet  the  competition. 
The  half-school  thus  avoids  loss  of  time  to  the  student  and  loss  of  students  to  the 
university.  The  arrangement  took  advantage  of  the  break  in  the  middle  between 
the  laboratory  and  the  clinical  years;  but  a  deeper  reason  made  the  experiment 
feasible. 

The  bachelor's  course  has  under  modern  conditions  a  double  aim :  it  is  simultane- 
ously cultural  and  vocational.  The  sciences  fundamental  to  medicine  have  obviously 
both  characters:  they  are  vocational  to  the  extent  that  they  are  instrumentally  in- 
dispensable; they  are  cultural,  as  is  all  enlarging  and  releasing  experience,  whether 
of  men,  books,  or  travel.  Culture  is  indeed  in  this  aspect  an  incidental  value  of  all 
novel  experience.  So  far,  then,  the  combined  course  may  be  fairly  said  to  be  feasible, 
because  it  enriches  the  college  curriculum ;  and  the  college  may  do  well  to  offer  the 
opportunity. 

Is  the  scheme  equally  sound  from  the  standpoint  of  medical  education  ?  The  pro- 
fessional and  cultural  standpoints,  though  obviously  overlapping,  are  not  identical. 
The  professional  purpose  involves  greater  concentration,  is  on  the  lookout  for  definite 
correlations,  and  steers  towards  an  evident  practical  goal.  The  medical  curriculum 
possesses  a  certain  organic  unity  in  virtue  of  the  fact  that  each  of  its  parts  does  this 
same  thing.  The  college  as  college  is  indifferent  to  the  ultimate  practical  bearing; 
the  medical  school  cannot  afford  to  forget  it.  As  to  certain  subjects,  indeed,  there 
is  perhaps  little  to  choose.  The  college  has  already  taken  chemistry  wholly  out  of  the 
medical  curriculum ;  it  may  be  allowed  to  take  bio-chemistry,  too.  In  reference,  how- 
ever, to  other  subjects,  pathology,  physiology,  etc.,  it  is  important — once  more 
from  the  standpoint  of  medical  education — to  distinguish  between  two  forms  which 
the  combined  course  assumes.  To  take  advantage  of  it  at  Columbia  or  Michigan — 
complete  four-year  schools — the  student  goes  over  into  the  medical  department, 
which  is  compactly  organized  with  laboratories  and  clinics  interwoven.  He  spends 
the  entire  period  of  four  years  there.  The  college  has  nothing  to  do  with  it  beyond 
registering  his  credits  for  the  first  two  years  towards  his  A.B.  degree.  That  fact  makes 
absolutely  no  difference  to  the  medical  teachers.  The  student  is  trained  for  four  years 
just  as  he  would  be  trained  if  he  had  his  A.B.  degree  to  start  with.  The  combined 
course  in  this  form  exacts  no  sacrifice  from  the  medical  school. 

In  the  case  of  the  half-school  or  the  divided  school  the  situation  is  different:  the 
medical  subjects  are  apt  to  be  parceled  out  among  the  general  scientific  laboratories, 
and  there  are  no  clinics  or  clinicians  at  all.  The  professors  themselves  may  lack  medi- 
cal training.  There  is  no  observable  goal  to  steady  or  beckon  the  teacher.1  Counting 

1  The  medical  department  of  the  University  of  Wisconsin,  a  half-school,  combats  the  difficulty  by 
appointing  a  professor  of  clinical  medicine. 


THE  LABORATORY  BRANCHES  75 

the  two  years'  work  as  the  latter  half  of  the  A.  B.  course  may,  under  these  circum- 
stances, distinctly  weaken  it  from  the  medical  standpoint.  It  is,  of  course,  true  that 
the  German  medical  schools  are  without  the  sort  of  organization  we  are  now  empha- 
sizing; but  they  have  what  we  lack,  ideals  and  traditions.  Dispersion  does  not  cost 
them  their  point  of  view.  When  our  ideals  are  as  sound,  we  too  may  be  capable  of 
dispensing  with  a  more  or  less  formal  organization.  Some  of  our  schools  may  already 
be.1  Would  it,  however,  be  equally  safe  even  in  Germany,  if  there  were  no  clinics 
at  all? 

Take,  for  instance,  the  subject  of  pathology.  The  two-year  school,  remote  from  hos- 
pitals and  autopsies,  can  provide  museum  specimens,  models,  and  microscopic  mounts. 
Under  favorable  conditions,  animal  experimentation  can  still  further  supplement  its 
resources.  But  the  pathologist  will  suffer  from  isolation;  he  is  part  of  the  college,  but 
not  part  of  a  hospital,  and  what  is  hurtful  to  him  cannot  be  helpful  to  his  students. 
For  them  much  depends  on  the  arrangement  of  courses  in  the  institution  to  which 
they  emigrate  for  their  third  and  fourth  years.  Meanwhile,  in  any  case,  at  the  fateful 
moment  of  their  introduction  to  the  subject,  however  admirably  they  may  have  been 
drilled  in  the  specific  content  of  the  course,  little  advantage  can  be  taken  of  their 
general  absorptive  power.  For  even  a  fair  student,  while  learning  his  lessons  in  patho- 
logical histology,  might  assimilate  incidentally  much  that  goes  beyond.  Not  infre- 
quently what  is  most  stimulating  in  his  experience  would  be  thus  obtained.  It  would 
appear,  then,  that,  while  the  college  will  surely  gain,  it  is  not  certain  that  the  medi- 
cal curriculum  may  not  lose  when  the  first  and  second  years  are  separated  or  de- 
tached. 

There  would  be  the  less  necessity  for  the  cautious  attitude  here  taken  in  reference 
to  the  two-year  school  if  these  departments  were  everywhere  organized,  as  they  have 
been  by  Wisconsin,  Cornell,  Missouri,  and  Indiana,  with  a  keen  appreciation  of  the 
ditiiculties  to  be  surmounted  and  with  financial  resources  capable  of  coping  with  them. 
Apparatus,  books,  animals,  laboratory  material,  must  be  provided  in  abundance.  In 
the  institutions  above  mentioned  they  are.  Too  frequently,  however,  apparatus  is 
limited,  books  are  scarce,  animals  hard  to  get,  running  expenses  reduced  to  a  mere  pit- 
tance. Skilled  assistants  and  competent  helpers  may  also  be  lacking.  The  teachers  are 
young  and  well  trained;  but  their  professorial  salaries  are  paid  to  them  in  part  for 
menial  labor.  They  care  for  apparatus,  get  it  out,  put  it  away,  prepare  all  demon- 
strations and  experiments,  and  clean  up  after  class.  Be  the  students  ever  so  few,  rou- 
tine drudgery  and  isolation  will  wear  out  the  enthusiasm  of  their  instructors.  The 
men  will  grow  stale,  the  department  sterile.  As  the  two-year  schools  now  generally  re- 
quire two  years  of  college  work  for  entrance,  they  cannot  be  parsimoniously  organ- 
ized. Yet  their  rapid  spread  seems  to  indicate  a  mistaken  notion  that  the  laboratory 
years  can  safely  be  conducted  on  a  small  scale  at  comparatively  slight  expense. 

1  For  an  extremely  lucid  and  able  discussion  from  this  point  of  view  see  the  Harvard  Bulletin,  Nov.  3, 
1909 :  "Education  in  Medicine:  The  Relations  of  the  Medical  School  to  the  College." 


76  MEDICAL  EDUCATION 

A  uniform  or  fixed  apportionment  between  various  subjects  is  in  schools  of  the 
highest  grade  neither  feasible  nor  desirable.  The  endeavor  to  improve  medical  edu- 
cation through  iron-clad  prescription  of  curriculum  or  hours  is  a  wholly  mistaken 
effort;  while  mechanical  regulation  cannot  essentially  improve  the  poorer  schools,  it 
may  very  seriously  hamper  competent  institutions.  There  is  no  one  way  to  study 
medicine,  still  less  one  way  to  advance  it.  If  the  teaching  is  in  inferior  hands,  printed 
directions  will  not  save  it.  The  prescribed  curriculum  is  a  staff  upon  which  those 
lean  who  have  not  strength  to  walk  alone. 

Fortunately,  current  practice  varies  widely.  The  Johns  Hopkins,  for  example,  offers 
700  hours'  instruction  in  anatomy,  of  which  about  400  are  required,  Harvard  427 ; 
Rush  gives  108  hours  to  histology,  Cornell  265;  Columbia  requires  490  hours  in 
anatomy,  embryology,  and  histology;  Harvard  gives  513  hours  to  pathology,  Western 
Reserve  304.  These  discrepancies  are  of  slight  importance,  for  the  medical  curriculum 
is  throughout  constituted  of  overlapping  parts :  apparent  deficiencies  in  one  subject 
are  supplied  in  another.  Physiology  revises  and  mends  anatomy,  and  the  clinical  years 
may  be  safely  relied  on  to  build  out  here  and  there  the  details  of  pathology.  A  certain 
carefully  selected,  irreducible  minimum  in  each  subject  must  of  course  be  common 
throughout  these  institutions;  the  rest  may  be  left  open,  to  vary  from  school  to 
school,  and  within  each  school  to  vary  to  some  extent  with  different  individuals.  The 
medical  school  is  above  collegiate  grade ;  it  is  a  professional  school  on  a  college  basis. 
Its  students  are  presumably  mature  and  will  doubtless  prove  increasingly  well  trained. 
They  are  fit  to  be  trusted  with  a  certain  degree  of  discretion,  in  a  field  within  which 
selection  between  alternatives  of  equal  importance  must  in  any  event  take  place. 
The  fourth  year  at  Harvard  is  left  open  to  choice ;  at  Johns  Hopkins  one-fourth  of 
each  year  is  subject  to  election  ;  intensive  study  at  certain  points  is  encouraged  with- 
out endangering  the  fundamentals  common  to  all.  The  problem  of  medical  education 
and  orientation  is  not  otherwise  manageable.  In  the  effort  to  force  every  important 
subject  as  it  has  developed  into  the  common  curriculum — be  it  ever  so  inadequately 
— the  average  curriculum  now  calls  for  something  like  4000  hours  of  prescribed  work. 
The  demand  is  an  impossible  one.1  It  originates  partly  in  the  effort  to  make  the  medical 
school  repair  the  omissions  of  preliminary  education;  higher  standards  will  relegate 
something  at  least  to  the  high  school  and  college,  and  so  far  relieve  congestion.  As 
for  the  rest,  we  require  a  modified  conception  of  what  any  sort  of  school  can  and 
ought  to  attempt.  The  mature  student,  competently  guided,  needs  not  to  be  policed 
like  the  "breeching  scholar  in  the  schools."  His  every  moment  must  not  be  preempted 
by  an  assigned  task.  Von  Striimpell  rebukes  the  same  tendency  in  Germany:  "Some- 
what more  rarely  in  the  first,  very  often,  however,  in  the  later  semesters,  many  students 
hear  lectures  for  eight  to  ten  hours  a  day.  From  morning  to  night  their  time  is  taken 
up  with  classes;  they  rush  out  of  one  lecture  hall  into  another,  hearing  a  huge  mass 
of  facts  and  theories  put  forward.  One  can  readily  imagine  the  condition  inside  their 
1  A  large  percentage  of  students  are  making  up  preliminary  "conditions"  besides. 


THE  LABORATORY  BRANCHES  77 

heads  by  the  time  night  comes.  The  actual  outcome  of  this  absurd  overcrowding  is 
that  only  a  small  amount  of  what  is  heard  is  retained.  One  can  profitably  listen  only 
when  one  can  take  in  readily  and  follow  up  systematically  with  work  at  home."1 

The  maturity  of  the  student  body  at  this  level  makes  possible  another  innovation. 
The  low  standard  or  immature  type  of  medical  student  must  have  his  medical 
knowledge  carefully  administered  in  homeopathic  doses.  He  carries  a  half-dozen 
studies  simultaneously  because  his  untutored  interest  fatigues  easily  and  his  assimi- 
lative ability  in  any  one  direction  is  relatively  slight.  Time  and  energy  are  of  course 
lost  in  hourly  breaking  off  one  connection  and  making  another.  But  it  is  unavoidable; 
the  practitioner  teacher  must  leave  at  the  close  of  his  "  hour"  anyhow.  At  the  uni- 
versity studies  may  be  concentrated.  The  laboratories  are  open  all  day;  the  profes- 
sors are  there  at  work.2  The  first  months  of  the  medical  curriculum  are  then  given 
over  to  anatomy  alone;  for  it  is  clearly  illogical  to  begin  even  physiology  till  the 
anatomist  has  made  some  headway.  Concentration 3  is  economical  of  time  and  energy, 
and  stimulates  the  student  to  push  on  beyond  definitely  prescribed  limits.  How  far 
it  can  wisely  be  carried  is  a  point  to  be  determined  by  experiment. 

The  schools  of  our  second  division — those  requiring  for  admission  high  school 
graduation  or  the  "equivalent" — move  within  narrower  limits.  Two  factors  are  at 
work.  Most  schools  of  this  class  live  on  their  fees;  McGill,  Toronto,  Tulane,  are 
among  the  few  that  are  enabled  by  additional  resources  to  provide  a  complete  lab- 
oratory outfit.  The  strongest  of  the  others,  Jefferson  and  Northwestern  University, 
for  example,  relying  practically  altogether  on  income  from  students,  can  at  best  de- 
velop highly  a  department  or  two;4  the  rest  are  necessarily  restricted.  The  quality  of 
the  student  body  is  likewise  a  limitation.  Laboratory  courses,  following  the  lines  that 
we  have  marked  out,  are  impossible  to  boys  whose  preliminary  training  in  science  has 
barely  begun.  At  best  the  students  have  an  elementary  acquaintance  with  physics  or 
chemistry;  frequently  not  even  that.  Those  that  have  and  those  that  have  not  sit  side 
by  side  on  the  same  benches.  A  difficult  dilemma  is  thus  presented.  It  is  impossible 
to  teach  the  medical  without  the  pre- medical  sciences;  the  medical  course,  already 
crowded,  cannot  be  either  cut  or  compressed  sufficiently  to  accommodate  them.  The 
situation  cannot,  therefore,  be  wholly  retrieved  within  the  medical  school.  Makeshifts 
vary  somewhat  from  school  to  school.  A  rigid  medical  curriculum,  clipped  to  the  quick, 
leaves  perhaps  a  few  hundred  hours  available  for  pre-medical  work.  Chemistry  as  a 
rule  absorbs  them  all;  nothing  is  attempted  in  biology;  occasionally  physics  gets  a 
slight  opportunity,  as  at  Tulane,  where  first-year  students  hear  one  lecture  a  week, 

1  Ueber  den  Medizinisch-Klinischen  Unterricht,  p.  11  (Leipzig,  1901).  To  the  same  effect.  Professor 
T.  Clifford  Albutt:  On  Professional  Education,  p.  49  (Macmiflan,  1906). 

2  "Die  Studierenden  sollen  jederzeit  eintreten  diirfen,"  Virchow's  laboratory  motto,  quoted  by  Orth : 
Berliner  Med.  Woch.  Sch.  vol.  xliii.  p.  820. 

3  See  "The  Concentration  Plan  of  Teaching  Medicine,"  by  H.  A.  Christian,  Proceed.  Asm.  Amer. 
Med.  Colleges,  March,  1910. 

*  See  p.  133. 


78  MEDICAL  EDUCATION 

"abundantly  illustrated,**  or  at  St.  Louis  University,  where  sixty-four  hours  of  didactic 
instruction  are  devoted  to  the  subject.1 

After  all,  however,  there  are  different  ways  of  meeting  even  a  desperate  condition ; 
and  in  this  instance  the  variations  are  within  limits  amazingly  wide.3  There  are  schools 
that  sink  ignominiously  without  a  struggle;  others  that  take  advantage  of  the  stu- 
dent's plight  to  palm  off  cheap  instruction  at  a  profit;  and  a  small  number  that  by 
valiant  effort  minimize,  and  to  no  slight  degree  surmount,  the  difficulty.  According 
as  an  institution  reacts  in  one  or  another  of  these  ways,  we  make  out  three  main 
varieties  among  schools  on  the  high  school  basis : 

1.  Those  that  by  careful  selection  of  students  and  extraordinary  pains  in  teaching 
make  the  very  most  of  the  situation; 

2.  Those  that,  content  to  operate  on  a  lower  plane,  are  still  commercially  effective; 
8.  Those  that  are  frankly  mercenary. 

We  shall  briefly  consider  these  three  types  in  succession. 

(1)  These  schools  form  a  small  minority.  They  are  straining  hard  to  get  from  the 
high  school  to  the  college  basis;  in  equipment,  organization,  and  scientific  spirit 
they  are  to  greater  or  less  degree  already  there.  They  have  usually  four  scientific 
departments,8  already  in  most  instances  well  equipped,  each  in  charge  of  a  full-time 
professor,  for  whom  private  quarters  and  more  or  less  free  time 4  procure  some  op- 
portunity to  push  ahead.  Energy,  sincerity,  and  intelligence  are  abundantly  in  evi- 
dence throughout  these  institutions.  In  resources  they  vary  greatly,  but  in  spirit  they 
are  alike;  and  all  are  admirable.  Every  possible  point  is  scored :  the  more  difficult  the 
contest,  the  keener  the  play.  However  scant  the  resources,  something  is  put  into 
books;  however  hard  pressed  the  instructor,  a  museum,  carefully  catalogued  and 
labeled,  has  been  painfully  assembled. 

Of  schools  of  this  type,  two  Canadian  institutions — McGill  and  Toronto  —  de- 
serve especial  attention.  In  point  of  laboratory  equipment  they  equal  Minnesota  and 
Michigan;  their  lower  entrance  requirement,  minimized  by  conscientious  adherence 
to  a  strict  interpretation  of  their  announced  standards,  is  now  compensated  by  the 
addition  of  a  fifth  year  to  the  curriculum.6  At  Toronto  the  teaching  is  wholly  in 

1  Sometimes  the  provision  is  sheer  make-believe.  At  Denver  and  Gross  College  of  Medicine  (Denver, 
Col.)  the  physics  is  thus  described:  "  One  hour  each  week  in  practical  chemistry  as  applied  to  med- 
icine. The  first  year's  work  will  include  medical  physics,  chemic  philosophy,  and  organic  compounds." 
Catalogue,  1908-9,  p.  22. 

1  See  table  at  close  of  this  chapter. 

3  Anatomy,  chemistry,  physiology  (including  pharmacology),  pathology  (including  bacteriology  and 
hygiene). 

4  How  much,  depends  on  the  quality  of  the  assistants  furnished.  There  is  great  variation  in  this 
respect 

'This  is  a  very  different  thing  from  adding  a  year  devoted  to  pre-medical  sciences  taught  by  the 
medical  faculty  of  a  proprietary  school,  —  a  makeshift  without  possibility  of  development.  The  Cana- 
dian year  is  a  year  in  the  university,  where  teachers  of  science  are  in  position  to  do  their  subjects 
justice ;  eventually  a  second  year  will  be  demanded.  The  optional  fifth  year  offered  by  our  pro- 
prietary schools  is  commercially  profitable  and  educationally  futile.  See  page  47. 


THE  LABORATORY  BRANCHES  79 

charge  of  full-time  instructors,  for  whose  original  work  splendid  provision  has  been 
made  in  laboratories  of  ideal  construction  and  admirable  equipment.  McGill  is  in 
respect  to  full-time  teachers  somewhat  less  fortunate ;  but  its  great  museum,  recently 
much  damaged  by  fire,  proves  that  genuine  enthusiasm  may  succeed  contrary  to  all 
the  established  rules  of  the  game.  In  both  institutions  the  shortcomings  of  the  stu- 
dent body,  instead  of  excusing  perfunctory  work,  have  rather  been  regarded  as  an 
obstacle  to  be  overcome,  a  condition  to  be  met.  The  students  have  had  little  high 
school  science:  all  the  more  reason,  then,  to  provide  excellent  laboratories,  skilful 
teachers,  abundant  assistants.  In  keeping  with  effective  performance  are  their  mod- 
esty and  candor.  The  number  of  "greatest  anatomists"  and  "greatest  pathologists" 
teaching  on  small  salaries  in  obscure  places  in  the  United  States,  and  of  laboratories 
"  as  good  as  Johns  Hopkins,"  is  nothing  less  than  staggering.  Nor  is  a  boastful  pride 
in  mediocrity  lacking  even  in  institutions  of  some  real  merit.  At  Toronto  and  McGill 
one  hears  in  the  medical  schools  no  such  bravado.  There  they  deprecate  the  defects, 
which  they  hasten  to  show  for  fear  they  may  escape  notice.  The  absence  of  compe- 
tition1— be  it  business  competition  between  schools  conducted  for  profit,  or  academic 
competition  between  endowed  or  tax-supported  institutions,  mad  to  "make  a  show- 
ing"— may  perhaps  be  responsible  for  their  more  guarded  utterance  and  more  as- 
sured ideals. 

Perhaps  a  dozen  institutions  in  the  United  States  belong  with  greater  or  less  right 
to  the  category  under  consideration.  Regard  being  had  to  the  quality  of  the  student 
body,  to  the  number  of  full-time  teachers  and  assistants,  and  to  the  adequacy  of 
laboratories,  museum,  and  library,  the  best  of  them,  in  respect  to  the  first  and  second 
years,  are  New  York  University,  Syracuse,2  Northwestern  University,  Jefferson  Medi- 
cal College  (Philadelphia),  Tulane  University  (New  Orleans),  St.  Louis  University, 
the  University  of  Texas,  handicapped  though  some  of  them  are  in  one  respect  or 
another  by  resources  inadequate  to  the  ambition  and  competency  of  their  faculties 
and  by  a  student  body  of  somewhat  uneven  composition.  St.  Louis  University  affords 
an  excellent  example  of  a  brave,  uphill  contest,  by  no  means  barren  of  result.  Unable 
for  the  moment  to  do  all  it  wishes,  it  has,  like  a  good  general,  concentrated  its 
effort  at  critical  points.  It  secures  a  pervasive  scientific  atmosphere  in  the  first  two 
years  through  the  intensive  cultivation  of  anatomy  and  physiology.  The  departmental 
head  of  the  former  subject  stipulated  that  his  routine  work  be  kept  in  close  bounds; 
with  wise  liberality  he  has  been  provided  with  an  assistant  professor,  a  draughtsman, 
and  a  competent  helper;  the  productive  department  thus  created  has  invigorated  the 
entire  school  on  the  laboratory  side. 

To  the  schools  just  described  we  must  look  for  such  further  facilities  in  high-grade 
medical  education  as  the  country  still  requires.  Their  ideals  are  correct ;  they  lack 
only  the  means;  and  these  they  have  already  in  comparative  poverty  shown  the  ca- 

1  There  are  eight  medical  schools  in  British  America. 

2  Already  requiring  more  than  four-year  high  school  education. 


80  MEDICAL  EDUCATION 

pacity  to  use.  Once  the  necessary  resources  have  been  bestowed  upon  them,  the  re- 
maining task  will  be  merely  the  absorption  or  the  suppression  of  the  various  types 
of  medical  school  yet  to  be  discussed.  It  is  surely  significant  that  with  but  a  single 
exception,  these  schools  are  also,  like  those  of  the  first  division,  bona-Jide  university 
departments. 

So  much  for  the  best  type  of  medical  school  on  the  high  school  basis.  We  consider 
next  (2)  the  schools  that  on  the  same  basis  are  shrewdly  and  more  or  less  outspokenly 
commercial.  A  few  of  them — those  at  Chicago,  Philadelphia,  and  Baltimore — have 
accumulated  extensive  and,  in  one  or  two  departments,  elaborate  plants.1  They  are 
on  a  routine  level  and,  within  the  limits  marked  out  by  state  board  examinations, 
pedagogically  effective.  They  drill  their  students  energetically  in  the  elements  of  such 
of  the  sciences  as  they  touch  at  all,  but  the  atmosphere  is  at  best  that  of  a  success- 
ful factory.  There  is  no  free  scientific  spirit.  The  teaching  of  chemistry  at  the  Medico- 
Chirurgical  College  of  Philadelphia  is  an  extreme  case  in  point.  The  course  is  sub- 
divided into  fixed  lessons,  each  of  them  so  much  raw  material,  for  which  the  student 
receives  a  voucher,  to  be  returned  in  proper  shape  before  he  can  get  the  voucher  for 
the  succeeding  task.  The  vouchers  returned  constitute  an  automatic  record  of  atten- 
dance and  form  the  basis  of  an  oral  quiz  by  an  instructor.  "The  whole  system  is  an 
imitation  of  the  business  system  in  vogue  in  the  better  organized  business  offices."" 2 
Mechanically  admirable,  no  doubt;  but  what  convincing  evidence  the  system  itself 
affords  of  the  unfitness  of  the  students  for  the  study  of  modern  medicine! 

Two  schools  of  this  group — the  Long  Island  College  Hospital  (Brooklyn)  and  the 
Albany  Medical  School — are  closely  affiliated  with  laboratories  which  provide  good 
teaching  in  certain  branches :  the  Hoagland  Laboratory  at  Brooklyn  relieves  the  school 
of  histology,  pathology,  and  bacteriology;  the  Bender  Laboratory  at  Albany  carries 
the  laboratory  work  in  the  same  subjects.  It  will  be  noted  that  physiology  and 
pharmacology  are  not  properly  provided  by  either;  neither  are  they  by  the  school. 
One  might  suppose  that  the  school,  relieved  at  one  point,  would  become  more  effec- 
tive at  another.  Not  at  all.  Both  schools  pay  in  dividends  to  prosperous  practitioners 
the  sums  that  should  be  used  in  completing  their  fundamental  instruction. 

Scientifically,  then,  these  schools  may  be  called  inert.  They  rarely  cultivate  any  re- 
search at  all;  their  faculties  are  generally  composed  of  active  practitioners  whose 
training  has  rarely  been  modern.  By  way  of  exception  Louisville  has  four  full-time 
professors  in  the  fundamental  branches,  the  Medico-Chirurgical  three,  Creighton  one. 
But  very  rarely  has  the  full-time  teacher  opportunity  to  work  ahead.  His  time  and 
energies  are  bespoken  by  heavy  routine,  unlightened  by  a  competent  or  organized 
force  of  assistants  and  helpers.  In  general,  school  positions  are  valued  as  professional 

1  Preeminently  the  Medico-Chirurgical  (Philadelphia),  University  of  Maryland  and  College  of  Physi- 
cians and  Surgeons  (Baltimore),  and  College  of  Physicians  and  Surgeons,  Chicago. 

'  From  a  description  by  the  head  of  the  department. 

•Strictly  speaking,  even  these  are  not  full-time  men  in  the  medical  school,  since  they  also  teach  in 

pharmacy  and  dental  departments. 


THE  LABORATORY  BRANCHES  81 

stepping-stones,  not  as  scientific  opportunities;  laboratories  are  often  slovenly  and,  ex- 
cept during  class  hours,  entirely  abandoned.  Strange  professorial  combinations  are 
found :  anatomy  and  surgery,  very  commonly ;  clinical  medicine  and  physiology,  at 
the  University  of  Maryland;  orthopaedic  surgery  and  pathology,  at  the  Baltimore 
Medical  College ;  medicine  and  pathology,  at  the  Chicago  College  of  Medicine  and 
Surgery  (Valparaiso  University);  pathology  and  the  physical  directorship  of  the 
academic  department,  at  Bowdoin.  Scientific  chairs  are  held  by  non-residents  at  the  Uni- 
versities of  Colorado l  and  Vermont2  and  at  the  Medical  School  of  Maine  (Bowdoin);  * 
and  itinerant  teachers,  giving  the  same  branches  at  several  schools,  are  to  be  found 
in  Philadelphia,  New  York,  and  Chicago.  If  the  larger  institutions  under  consideration 
chance  to  contain  a  full-time  teacher,  his  time  usually  belongs  equally  to  dental  and 
pharmacy  departments,  developed  as  "business  propositions"  to  keep  the  plant  con- 
stantly going;  despite  the  manifest  incongruity,  dental  or  pharmacy  students  mingle 
in  the  same  classes  with  medical  students  at  the  Medico-Chirurgical  College  (Phila- 
delphia), Temple  University  (Philadelphia),  and  the  Creighton  Medical  College 
(Omaha).4  Occasionally  a  non-practising  teacher  will  be  found  who  is  simultaneously 
holder  of  a  municipal  office,  to  which  he  devotes  his  main  thought.  The  medical 
school  gets  the  few  brief  hours  that  it  pays  for.  Thus  the  non-practising  professor 
of  chemistry  at  the  Creighton  school  is  the  city  gas  inspector;  the  professor  of  bacteri- 
ology at  Denver  and  Gross  is  city  bacteriologist,6  with  his  laboratory  at  the  City 
Hall.  In  the  few  cases  where  a  non-practising  full-time  professor  is  found,6  he  is 
swamped  with  work ;  for  he  has  as  a  rule  only  student  assistants  to  aid  him  in  coping 
with  several  hundred  pupils  utterly  inexperienced  in  laboratory  manipulation. 

For  many  years  a  school  of  this  sort  was  a  veritable  gold  mine  to  its  owners.  Fees 
were  divided  outright,  or  invested  in  buildings  which  the  faculty  owned.  Once  in 
a  while  the  income  was  split:  a  large  share  went  to  the  teachers,  the  rest  was  de- 
voted to  carrying  mortgaged  buildings  held  by  the  trustees.  These  structures  them- 
selves were  not  infrequently  erected  in  pursuance  of  business  policy.  Recent  agita- 
tion has  forced  increased  expenditure  on  buildings  and  equipment.  The  schools 

1  Anatomy,  by  a  non-resident  surgeon. 

2  Physiology,  pathology,  and  hygiene. 

3  Anatomy  and  physiology. 

*  Likewise  at  University  of  Maryland,  Valparaiso  University,  College  of  Physicians  and  Surgeons 
(Chicago),  Georgetown  University,  College  of  Physicians  and  Surgeons  (Baltimore),  Baylor  Univer- 
sity, College  of  Physicians  and  Surgeons  (San  Francisco),  Barnes  (St.  Louis),  Starling-Ohio,  Univer- 
sity of  Texas,  Toledo  Medical  College,  Medical  College  of  the  State  of  South  Carolina,  Milwaukee 
Medical  College,  College  of  Physicians  and  Surgeons  (Boston),  Wisconsin  College  of  Physicians  and 
Surgeons.  Even  at  Harvard,  dental  and  medical  students  are  mixed  in  some  classes,  though  it  is 
admitted  that  "the  Dentals  don't  do  as  well  and  are  harder  to  teach."  Students  are  admitted  to  the 
Harvard  Dental  School  on  the  basis  of  a  four-year  high  school  education.  The  discrepancy  is  there- 
fore considerable. 

5  The  same  is  true  at  the  University  of  Oregon  (Portland),  though  in  this  case  the  laboratory  is  in  the 
medical  college ;  it  is  also  the  only  real  laboratory  there. 

«  Physiology,  College  of  Physicians  and  Surgeons  (Chicago) ;  pathology,  Creighton ;  chemistry,  Balti- 
more Medical  College. 


82  MEDICAL  EDUCATION 

have  been  willing  enough  to  build;  but  in  the  matter  of  equipment  they  have  usu- 
ally yielded  as  little  as  they  could.  The  conclusive  evidence  of  lack  of  educational 
conscience  or  pride  is  the  general  absence  of  a  decent  museum.1  Material,  of  course, 
abounds,  the  expense  involved  is  slight;  but  the  practitioner  simply  will  not  take 
the  trouble.  The  College  of  Physicians  and  Surgeons  (Baltimore),  Georgetown  Uni- 
versity (Washington),  Long  Island  College  Hospital  (Brooklyn),  the  medical  depart- 
ment of  Valparaiso  University,  the  Chicago  Hahnemann,  Ensworth  (St.  Joseph,  Mis- 
souri), are  among  the  schools  that  have  little  or  nothing  in  the  way  of  a  museum  at 
all.  Such  specimens  as  one  meets  are  often  putrid,  rarely  labeled  properly,  and  still 
more  rarely  catalogued.  But  a  few  exceptions  may  be  fortunately  noted :  the  great 
anatomical  and  pathological  museum  at  McGill  has  already  been  mentioned.  To  the 
same  class  belong  the  excellent  collections  made  by  Souchon  at  Tulane  and  by  Keiller 
at  Galveston  (University  of  Texas).  A  small  but  beautifully  mounted  collection  at 
Boston  University  is  once  more  an  evidence  of  what  conscience  and  intelligence  will 
achieve  despite  slender  financial  resources. 

Practically  the  same  may  be  said  on  the  subject  of  books.  The  College  of  Physi- 
cians and  Surgeons  of  Chicago  and  the  Medical  College  of  Virginia  have  small  work- 
ing libraries;  but  in  general  no  funds  are  set  aside  for  the  purchase  of  books.  The 
school  grind  is  merrily  independent  of  medical  literature.  The  University  of  Mary- 
land possesses  indeed  a  large  library  under  a  separate  roof,  but  the  building  was  un- 
heated  when  visited  in  midwinter,  and  at  best  it  is  open  only  two  hours  a  day. 
Denver  and  Gross  (Denver,  Colorado)  and  the  Medico-Chirurgical  College  of  Phila- 
delphia have  limited  accumulations  of  textbooks  and  cheap  medical  periodicals;8 
Long  Island  and  Albany  have  no  books  at  all.  In  the  College  of  Physicians  and  Sur- 
geons, Los  Angeles,  the  word  "Library"  is  prominently  painted  on  a  door  which,  on 
being  opened,  reveals  a  class-room  innocent  of  a  single  volume.  Once  more  it  is 
pleasant  to  record  exceptions:  a  good  library,  excellently  administered,  is  to  be 
found  at  Jefferson,  at  Buffalo,  and  at  Galveston. 

In  the  matter  of  laboratory  equipment  and  work,  our  progress  may  be  facilitated 
by  simple  elimination.  None  of  these  schools  has  laboratories  of  pharmacology;  in 
consequence,  their  teaching  of  materia  medica  and  therapeutics  is  wholly  on  didactic 
lines.  Only  a  few  of  them — the  Medico-Chirurgical  (Philadelphia),  University  of 
Maryland  (Baltimore),  the  College  of  Physicians  and  Surgeons,  Chicago — are  well 
equipped  to  do  either  demonstrative  or  experimental  work  in  physiology;  as  a  rule, 
physiology  is  still  didactically  presented  with  a  varying  amount  of  experimental 
demonstration.  The  general  laboratory  equipment  is  therefore  limited  to  chemistry, 
anatomy,  pathology,  and  bacteriology. 

lThc  Hahnemann  (Philadelphia),  University  of  Maryland  (Baltimore),  Oakland  College  of  Medicine 
and  Surgery  (California),  each  has  a  small  museum. 

•The  former  behind  a  counter  in  the  business  office, — practically  inaccessible;  the  latter  at  the  Col- 
lege Club  House. 


THE  LABORATORY  BRANCHES  83 

As  a  rule,  chemistry  advances  little  beyond  the  high  school  level;  at  the  best, 
elementary  organic  chemistry  is  included.1  The  equipment  is  ordinary;  there  is  no- 
where the  faintest  evidence  of  independent  scientific  interest,  nowhere  any  interplay 
between  the  chemical  and  other  laboratories.  The  ground  covered  satisfies  the  state 
board  prescription,  enabling  the  student  to  pass  the  state  board  examination.  No- 
thing more  is  intended;  the  teaching  is  accordingly  in  large  measure  didactic  and 
quiz  drill.  It  cannot  be  otherwise;  for  even  in  the  cases  where  sufficient  desk  space 
is  provided,  competent  assistants  are  lacking.  The  instruction  therefore  quickly  de- 
teriorates into  demonstration  and  drill. 

The  teaching  of  anatomy  clings  to  thoroughly  conventional  lines.  Embryology  is 
practically  unknown;  osteology  is  taught  by  lectures  instead  of  by  practical  methods, 
such  as  modeling,  or  the  like;  histology  is  relegated  to  pathology  because  the  ana- 
tomical department  possesses  no  microscopes,  in  the  first  place,  and  because  the 
practitioner  teacher  rarely  understands  their  use,  in  the  second.  The  laboratory  is  a 
mere  dissecting-room,  in  which  the  student  is  required  to  dissect  part  of  a  cadaver 
under  the  guidance  of  upper-class  students  or  recent  graduates.  Into  none  of  the 
schools  mentioned  have  modern  ideas  as  to  the  conduct  of  this  department  per- 
meated. Well  conducted  anatomical  laboratories  are  in  these  days  clean,  attractive, 
sweet-smelling  places;  the  cadavers,  neatly  covered  when  not  in  use,  are  moist, 
thoroughly  well  preserved,  and  not  repulsive  even  to  a  layman.  The  dissecting-rooms 
under  discussion  are  rarely  clean,  always  unattractive,  and  not  infrequently  unplea- 
sant. They  contain  tables,  cadavers,  and  a  vat;  usually  nothing  more.  Not  infre- 
quently the  school  skeleton  is  defective,  as  at  Creighton,  the  College  of  Physicians 
and  Surgeons,  Milwaukee,  and  at  the  Kansas  City  Hahnemann.  The  models,  charts, 
cross-sections,  bone-sets,2  drawings,  microscopes,  that  complete  the  outfit  of  the  modern 
anatomist,  are  conspicuously  absent.  Large  and  financially  prosperous  schools,  such 
as  the  Medico-Chirurgical  (Philadelphia),  the  University  of  Maryland  (Baltimore), 
in  immediate  proximity  to  institutions  like  the  University  of  Pennsylvania  and  the 
Johns  Hopkins,  where  the  subject  is  properly  conducted,  have  profited  nothing  by 
opportunities  to  modernize  their  teaching.  Of  course  it  could  not  be  otherwise.  The 
professor  is  a  busy  physician  or  surgeon.  He  lectures  to  ill  prepared  students  for 
one  hour  a  few  times  weekly,  in  a  huge  amphitheater,  showing  a  bone  between  his 

1  The  Medico-Chirurgical  College  of  Philadephia  offers  decidedly  more.  The  instruction  there  occu- 
pies part  of  three  years  and  requires  544  hours  of  work.  Nothing  could  better  illustrate  our  conten- 
tion that,  with  medical  students  on  the  high  school  or  equivalent  basis,  anything  like  a  thorough 
treatment  of  the  pre-medical  sciences  within  the  medical  curriculum  is  fatal  to  the  medical  curriculum 
itself.  Chemistry  here  takes  up  over  one-eighth  of  the  entire  medical  curriculum.  Of  course  physics  and 
biology  deserve  something  too,  though  they  get  practically  nothing.  What  would  happen  to  the  medi- 
cal curriculum  if  a  similar  effort  were  made  to  teach  them  thoroughly?  For  the  time  being,  the  in- 
struction limps  along  without  them.  When  their  necessity  is  generally  recognized,  as  that  of  chemistry 
is  now  recognized,  it  will  be  impossible  to  attempt  them  within  the  medical  school,  and  the  battle 
for  the  preliminary  scientific  training  will  have  been  won. 

2  At  Cornell  (Ithaca)  a  complete  set  of  bones  is  given  out  to  each  student.  There  are  over  100  com- 
plete skeletons.  This  makes  a  striking  contrast  with  numerous  schools  that  do  not  possess  a  single 
complete  skeleton. 


84  MEDICAL  EDUCATION 

finger-tips  or  eloquently  describing  an  organ  which  no  one  but  the  prosector  dis- 
tinctly sees;  at  the  close  of  which  oratorical  performance  he  snatches  his  hat  and, 
amid  mingled  applause  and  cat-calls,  makes  for  his  automobile  to  begin  his  round 
of  daily  visits.  In  the  afternoons  "demonstrators"  supervise  the  dissecting,  where 
eight  or  ten  inexpert  boys  hack  away  at  a  cadaver  until  it  is  reduced  to  shreds.  The 
actual  emphasis  falls  on  the  didactic  teaching  and  the  quiz-drills;  something  like 
half  the  student's  time  is  spent  in  the  lecture-room:  220  out  of  450  hours  at  Louis- 
ville, 360  out  of  684  at  the  College  of  Physicians  and  Surgeons  (University  of  Illi- 
nois), Chicago.  The  really  effective  work  is  not  infrequently  done  by  quiz-masters, 
who  drill  hundreds  of  students  in  memorizing  minute  details  which  they  would  be 
unable  to  recognize  if  the  objects  were  before  them.  This  is  a  flourishing  industry 
in  "great  medical  centers"  like  Chicago1  and  Philadelphia. 

Pathology  is  practically  in  the  same  condition.  The  best  of  these  schools  are  well 
supplied  with  microscopes,  microtomes,  and  material.  But  the  teaching  is  usually 
uninspired  routine  drill.  Sections  are  cut,  stained,  mounted,  and  observed.  At  the 
close  of  the  year  the  student  will  perhaps  have  accumulated  a  box  of  several  dozen 
slides,  which  he  may  carry  home  with  him.  But  the  work  has  been  largely  histolo- 
gical, — devoid  of  experimental  features,  on  the  one  hand,  and  but  feebly  articulated 
with  clinic  and  autopsy,  on  the  other.  The  autopsy  is  indeed  the  indispensable  ad- 
junct of  an  effective  department  of  pathology.  "A  course  in  pathology  without  au- 
topsy work  and  fresh  material  is  like  a  course  in  systematic  botany  without  field 
work."2  The  facilities  of  all  but  a  few  of  our  best  schools  are  in  this  respect  unduly 
limited;  at  no  other  point  is  the  lack  of  a  hospital  under  school  control  more  acutely 
felt.  Makeshifts  of  various  kinds  are  invoked  by  way  of  remedy :  in  New  York,  for 
example,  Columbia  and  Cornell  have  attached  the  two  coroner's  physicians  who  serve 
in  the  autopsy-room  of  the  great  Bellevue  Hospital,  thus  procuring  fresh  material 
from  a  large  number  of  cases.  The  arrangement  still  leaves  the  professor  of  pathology 
himself  out  of  account.  Of  the  schools  belonging  to  the  class  under  consideration  few 
have  even  fair  opportunities  of  this  character;  some  of  them  rely  altogether  on  a 
friendly  coroner's  cursory  performance  in  the  rear  room  of  an  undertaker's  establish- 
ment.3 The  classes  at  the  University  of  Maryland  witness  "perhaps  ten  [autopsies] 
a  year;""  the  College  of  Physicians  and  Surgeons,  Baltimore,  describes  its  opportu- 
nities as  "restricted;"  Georgetown  University  (Washington)  gets  a  "few,"  Hahne- 
mann  (Chicago),  "four  or  five  a  year;"  at  Northwestern  they  are  "scanty,  the  stu- 
dents do  none;"  at  Cooper  (San  Francisco)  they  are  scarce.  For  the  most  part,  the 
student  has  merely  made  the  microscopic  rounds  of  the  typical  abnormal  growths; 
his  fundamental  ignorance  of  biology,  which  no  serious  attempt  is  made  to  cure,  comes 

1 A  Chicago  drill-master  is  reported  as  having  classes  of  300. 

1  Letter  from  Richard  M.  Pearce,  professor  of  pathology.  University  and  Bellevue  Hospital  Medical 

College  (New  York  University). 

*e.g..  University  of  Oregon,  Portland. 


THE  LABORATORY  BRANCHES  85 

between  him  and  a  really  intelligent  grasp  of  the  principles  and  bearing  of  pathology. 
One  is  not  surprised  to  find  the  instruction  once  more  heavily  inclined  to  the  didactic 
side :  72  out  of  144  hours  at  the  College  of  Physicians  and  Surgeons,  Chicago;  90  out 
of  140  at  the  College  of  Physicians  and  Surgeons,  Baltimore.1 

Bacteriology — the  last  of  the  sciences  concerning  which  there  is  even  a  pretense 
— fares  in  general  rather  worse.  At  the  Medico -Chirurgical  of  Philadelphia  the  sub- 
ject is  the  best  developed  of  all  the  scientific  branches;  elsewhere  it  is  a  mere  tag  to 
pathology.  Sterilizers,  incubators,  and  culture- tubes  are  of  course  common  enough; 
this  is  the  orthodox  equipment,  stipulated  by  the  state  boards.  But  the  subject 
cannot  be  intelligently  studied  without  animals, — cats,  rabbits,  or  guinea  pigs.  In 
general,  one  finds  no  arrangements  to  care  for  animals  either  before  or  during  exper- 
imentation.2 As  a  rule,  "they  are  too  difficult  to  keep;"  at  Creighton,  Oakland 
(California),  the  Cleveland  College  of  Physicians  and  Surgeons,  the  University  of 
Vermont,  Georgetown  University  (Washington),  they  are  "got  as  needed," — else- 
where, often  not  even  then.  "I  think  I  am  not  violating  any  confidence,""  says  Dr.  Victor 
C.  Vaughan,3  "when  I  say  that  there  are  certain  men  who  teach  bacteriology  who 
start  at  the  beginning  of  their  lectures  with  a  lot  of  tubes  already  made.  They 
do  not  know  enough  about  bacteriology  to  make  cultures.  They  hold  up  these  tubes 
and  say,  'This  is  a  diphtheria  culture;  this  is  a  culture  of  tubercle  bacillus,'  and  if 
by  any  chance  a  culture  goes  bad,  they  send  and  get  another." 

(3)  There  yet  remains  for  our  consideration  the  third  variety  of  school  on  the  high 
school  or  equivalent  basis,  namely,  those  described  as  basely  mercenary.  In  point 
of  equipment  and  teaching  methods  these  schools  are  not  substantially  different  from 
institutions  on  a  still  lower  basis.4  Some  of  the  latter  institutions  show,  indeed,  a 
better  spirit :  the  University  of  Alabama,  at  Mobile,  the  College  of  Physicians  and 
Surgeons  and  the  School  of  Medicine,  at  Atlanta,  the  Medical  College  of  the  State 
of  South  Carolina,  at  Charleston,  are  not  without  traditions  and  a  certain  present 
dignity.  Educationally,  however,  subject  to  certain  exceptions  to  be  specified  from 
time  to  time,  they  may  without  violence  be  considered  together;  for  limitations  of 
one  kind  or  another — now  of  equipment,  now  of  intention,  again  of  both — make 
the  effective  teaching  of  any  of  the  laboratory  sciences  frankly  impossible.  They  are 
for  the  most  part  cramming  establishments,  in  many  of  which  it  is  freely  admitted 
that  the  students  do  not  even  own  the  regular  textbooks.  Their  main  weapon  is  the 
quiz-compend.  Such  laboratories  as  they  have  cannot  be  effectively  used;  of  teaching 
accessories — books,  museum,  modern  charts,  or  models — they  are  generally  devoid. 

1  At  the  Johns  Hopkins,  out  of  a  total  of  400  hours,  40  are  didactic ;  at  Minnesota,  out  of  456,  146; 
at  Wake  Forest,  out  of  195,  50. 

2  The  College  of  Physicians  and  Surgeons,  Baltimore,  operates  a  Pasteur  plant,  but  animals  are  only 
slightly  used  in  teaching. 

8  Third  Annual  Conference,  Council  on  American  Medical  Education,  American  Medical  Attociation, 

held  in  Chicago,  April  29,  1907,  p.  59. 

4  Those  in  the  south  and  elsewhere  asking  two  years  of  a  high  school,  or  less. 


86  MEDICAL  EDUCATION 

It  is  indeed  stretching  terms  to  speak  of  laboratory  teaching  in  connection  with 
them  at  all.1  It  is  hardly  more  than  make-believe;  in  the  better  schools,  a  futile  imi- 
tation, without  actual  bearing  on  the  subsequent  clinical  work ;  in  others,  a  grudg- 
ing compliance  with  the  state  board  behest;  occasionally  there  is  nothing  at  all. 
The  Mississippi  Medical  College  (Meridian)  did  not,  when  visited,8  own  a  dollar's 
worth  of  apparatus  of  any  description  whatsoever;  the  pathological  laboratories  of 
the  Chattanooga  Medical  College  and  the  College  of  Physicians  and  Surgeons,  San 
Francisco,  rejoice  in  the  possession  of  one  microscope  apiece;  Halifax  Medical  Col- 
lege provides  one  utterly  wretched  laboratory  for  bacteriology  and  pathology ;  the 
Toledo  school  has  a  meager  equipment  in  one  or  two  branches,  but  for  the  rest  is 
bare;  the  Detroit  Homeopathic  College  has  a  dirty  and  disorderly  room,  with  a  few 
dozen  wet  specimens,  that  is  called  the  pathological  laboratory;  at  the  Milwaukee 
Medical  College,  bacteriology  is  represented  mainly  by  several  wire  baskets  of  dirty 
test  tubes;  Temple  University  (Philadelphia)  has  no  individual  outfit  for  students 
in  any  science  at  all;  the  Chicago  National  Medical  University  is  practically  as  bare 
as  the  Meridian  school ;  the  eclectic  school  at  Lincoln,  Nebraska,  pretends  to  give 
clinical  instruction  in  Lincoln,  laboratory  instruction  at  Cotner  University,  a  few 
miles  from  town.  When  questions  are  asked  in  Lincoln  regarding  physiology  or  pa- 
thology, the  answer  is  made:  "That  is  given  at  Cotner ;"  when  the  same  question  is 
asked  at  Cotner,  it  is  answered:  "That  is  given  at  Lincoln."  A  quick  transit  from 
one  to  the  other  failed  to  find  anything  at  either.  Prestidigitation  is,  however,  fa- 
miliar enough  in  schools  of  this  grade.  Entrance  credentials  in  the  college  safe  fre- 
quently vanish  as  it  is  being  opened :  why  should  not  equipment  similarly  resent  in- 
spection? At  the  College  of  Physicians  and  Surgeons,  Denver,  the  outfit  in  pathology 
and  bacteriology  was  mostly  stored  in  a  certain  compartment  under  a  table.  There 
was  some  difficulty  and  delay  in  opening  it;  by  the  time  the  key  was  found,  every- 
thing had  disappeared  except  an  empty  demijohn  and  some  jugs,  obviously  too 
clumsy  to  whisk  themselves  away  in  such  airy  fashion.  At  Willamette  University 
(Salem,  Oregon)  "physiology  is  taught  experimentally."  The  apparatus?  "That  is 
kept  in  a  physician's  office  downtown."  At  the  Eclectic  Medical  College  of  New 
York  an  inquiry  was  made  as  to  the  teaching  of  experimental  physiology,  no  outfit 
for  which  had  been  noticed  in  the  course  of  the  inspection.  A  mere  oversight!  A  mes- 
senger was  despatched  to  fetch  it,  and  did — a  single  small  black  box,  of  about  the 
size  and  appearance  of  a  safety-razor  case,  containing  a  small  sphygmograph.  "Good 
standing"  requires  the  schools  of  St.  Louis  and  Chicago  to  own  a  certain  equipment 
in  experimental  physiology.  They  do;  it  is  displayed  prominently  on  tables,  brand- 
new,  like  samples  shown  for  sale  on  a  counter ;  the  various  parts  had  never  been  put 
together  or  connected  at  the  College  of  Physicians  and  Surgeons  or  at  the  Hippo- 

l«.y.t  Western  University  (London,  Ont.),  Halifax  Medical  College,  University  of  Arkansas,  South- 
western University  (Dallas,  Texas),  Fort  Worth  University,  Epworth  University  (Oklahoma  City). 
Other  examples  are  given  in  the  text. 

*  January  12,  1909.  It  was  then  in  its  third  year. 


THE  LABORATORY  BRANCHES  87 

cratean,  both  of  St.  Louis,  at  the  Western  Eclectic  (Kansas  City),  or  at  the  College 
of  Physicians  and  Surgeons  (Denver).  The  Littlejohn  School  of  Osteopathy  (Chicago) 
was  in  the  throes  of  rebuilding  to  accommodate  the  growing  classes  that  seek  its  su- 
perior advantages:  every  "laboratory"  but  that  of  chemistry  was  dismantled;  there 
was  no  prospect  that  they  could  be  again  set  up  for  months,  but  the  teaching  of 
"science"  went  on  just  the  same.1 

Chemistry  is  the  "star"  laboratory  course  of  these  schools — "medical  chemistry," 
of  course.  It  never  rises  above  a  fair  high  school  level  and  often  falls  far  below  it.  At 
Chattanooga  the  students  could  not  follow  the  subject,  however  simply  presented. 
The  laboratories  are  of  the  most  elementary  description, — sometimes  active  and  in 
good  order,  as  at  Mobile  and  Augusta,  at  the  Illinois  Medical  College,  and  at  the 
Eclectic  Medical  College  of  New  York ;  oftener  in  utter  disorder,  as  at  the  Maryland 
Medical  College  (Baltimore).  At  the  University  of  Oregon  (Portland)  and  Willamette 
(Salem,  Oregon)  there  is  no  running  water  at  the  desks ;  at  the  North  Carolina  Medi- 
cal College  (Charlotte)  a  single  set  of  reagents  is  provided  for  the  entire  class;  at  the 
University  Medical  College,  Kansas  City  (Missouri),  instead  of  individual  reagent 
sets,  huge  bottles  are  provided  for  general  use. 

Almost,  but  not  quite  all  the  schools  dissect.  At  Meridian  (Mississippi),  for  example, 
anatomical  material  is  too  difficult  to  get.  In  Chicago  they  have  learned  how  to  teach 
anatomy  practically  without  dissection.  At  the  National  Medical  University  the 
teacher  dictates,  the  students  learn ;  this  process  is  kept  on,  night  after  night,  from 
October  until  the  middle  of  April.  So  far  there  had  been  no  dissection  at  all,  but  there 
would  be  ultimately,  in  "May  or  June,"  though  there  were  no  cadavers  at  hand  as  yet. 
At  the  Jenner  Medical  College — also  aChicago  night  school — a  similarly  enlightened 
pedagogy  was  employed:  "the  subject  is  taught  by  lectures,  with  dissection  from 
May  15  until  the  close  of  the  session."  The  same  methods  are  practised  at  Pulte — 
the  Cincinnati  homeopathic  school — where  dissection  had  not  yet  begun  on  Decem- 
ber 14:  "the  anatomy  teaching  goes  on  independent  of  dissecting."  At  Kirksville, 
Missouri,  in  the  American  School  of  Osteopathy,  anatomy  is  taught  with  a  textbook 
the  first  year;  lectures,  demonstrating,  and  dissecting  are  postponed  to  the  second 
year, — and  the  whole  course  takes  but  three  years,  all  told.  The  Central  College  of 
Osteopathy,  Kansas  City,  Missouri,  holds  that  the  student  should  know  anatomy  be- 
fore he  dissects:  "he  will  get  more  out  of  it."  On  November  8  there  was  no  cadaver 
in  the  school:  they  already  had  had  one  and  "will  get  another  in  February."  At  the 
Bennett  Medical  College,  Chicago,  there  was  witnessed  a  quiz  in  anatomy  in  a  room 
without  a  skeleton,  bone,  or  chart.  At  the  College  of  Physicians  and  Surgeons,  Den- 
ver, it  was  impossible  to  find  any  evidence  of  active  dissecting;  and  it  was  admitted 
that  material  was  scarce:  "there  had  been  two  bodies  this  year,  ten  men  on  each." 

1  These  schools  are  generally  quite  devoid  of  teaching  aids,— charts,  modern  models,  etc.  The  rooms 
are  bare.  What  they  have  is  out  of  reach  of  the  students :  "if  it  were  not  locked  up,  it  would  disap- 
pear,"— a  significant  indication  of  the  sort  of  students  gathered  in  by  low  standards. 


88  MEDICAL  EDUCATION 

Elsewhere,  dissecting-rooms  are  indeed  found,  but  the  conditions  in  them  defy  de- 
scription. The  smell  is  intolerable ;  the  cadavers  now  putrid,  as  at  Temple  University 
(Philadelphia),  the  Philadelphia  College  of  Osteopathy,  the  Halifax  Medical  School, 
and  in  many 'of  the  southern  schools,1  including  Vanderbilt;  again,  dry  as  tanned  leather, 
— at  the  University  of  Tennessee,  Bennett  (Chicago),  Denver  and  Gross  (Denver), 
Creighton  (Omaha),  College  of  Physicians  and  Surgeons,  St.  Louis,  for  example.  At  the 
Barnes  Medical  College  (St.  Louis)  the  first-year  students  listen  to  lectures  only  in  the 
last  "semestry ;"  they  are  not  permitted  to  dissect  because  first-year  men  only  "hack 
and  butcher."  The  dissecting-room  of  the  Kansas  Medical  College,  Topeka  (the  medical 
department  of  Washburn  College), did  duty  incidentally  as  a  chicken  yard:  corn  was 
scattered  over  the  floor — along  with  other  things — and  poultry  fed  placidly  in  the 
long  intervals  before  instruction  in  anatomy  began. 

A  few  of  these  schools  have  the  apparatus  requisite  to  teach  pathology  and  bac- 
teriology in  routine  fashion:  the  Atlanta  College  of  Physicians  and  Surgeons,  for 
one.  But  in  general  they  own  an  inadequate  and  at  times  decreasing  supply  of  micro- 
scopes— for  every  where  one  hears  theft  assigned  in  extenuation  of  a  short  supply  or 
defective  instruments.  Post-mortems  are  practically  nil.  None  are  claimed  at  Chatta- 
nooga, Atlanta,  Charlotte  (North  Carolina),  or  Dallas  (Baylor  and  Southwestern  Uni- 
versities) ;  two  in  six  years  were  remembered  at  the  medical  department  of  the  Univer- 
sity of  Georgia  (Augusta).  In  default  of  post-mortems,  material  is  sometimes  obtained 
from  the  surgeons;  but  not  all  the  schools  can  even  then  prepare  it  properly.  To  cut 
matters  short,  hardened  material  and  sometimes  sections  are  bought  "in  the  east."  The 
student  at  most  stains  and  mounts  them.  Too  frequently  he  does  no  more  than  look 
at  them  through  the  microscope.  Whether  he  sees  anything,  remains  a  problem;  for 
he  rarely  makes  a  drawing.  In  many  cases  it  is  impossible  to  believe  that  even  this 
is  done.  At  the  College  of  Physicians  and  Surgeons,  St.  Louis,  individual  lockers  are 
provided;  on  examination  they  prove  to  be  empty.  An  explanation  is  offered:  "the 
boys  bring  slides  and  cover-glasses  along;  they  furnish  their  own  and  keep  them  at 
home." 

It  is,  of  course,  not  to  be  supposed  that  these  schools  would  be  materially  better 
even  if  well  equipped  and  decently  cared  for.  It  makes  very  little  difference  to  the 
student  body  that  they  assemble  whether  microscopes  and  incubators  are  provided 
or  not.  The  poor  fellow  who  in  an  unguarded  moment  is  caught  by  advertisements, 
premiums,  or  canvassing  agents2  cannot  be  taught  modern  medicine,  no  matter  what 
investments  in  apparatus  the  state  boards  force.  Meanwhile  the  sole  beneficiaries  of 
the  traffic  are  the  teachers — as  a  rule,  the  small  group  that  constitutes  the  "faculty ;" 
in  some  instances,  however,  only  the  dean,  who  "owns"  or  "runs"  the  school.  His 
associates  profit  indirectly  by  what  is  technically  known  as  the  "  reflex."  Their  pro- 

1  An  exception  must  be  recorded  in  favor  of  the  Memphis  College  of  Physicians  and  Surgeons,  where 
excellent  rooms  with  hot  and  cold  water  are  provided. 

1  Employed  at  Jefferson  Park  College,  feeder  to  the  Bennett  Medical  College,  Chicago. 


THE  LABORATORY  BRANCHES  89 

fessorial  dignity  impresses  the  crude  boys  who  will  be  likely  to  require  with  their 
first  cases  the  aid  of  a  "consultant."  The  "dean"  of  one  such  institution  was  frankly 
explaining  his  methods.  "What  do  you  give  your  teachers?"  he  was  asked.  "Titles," 
he  replied. 

The  less  obviously  commercial  schools  allege  not  infrequently  that  medical  edu- 
cation no  longer  pays,  that  it  is  kept  up  for  the  sake  of  the  "back  districts."  We 
have  already  shown  that  the  back  districts  deserve  and  can  get  something  better. 
Meanwhile  the  statement  does  not  persuade.  Hundreds  of  thousands  of  dollars  an- 
nually pour  into  these  institutions;  in  many  cases,  this  has  been  going  on  for  years. 
What  becomes  of  the  money?  There  is  in  general  nothing  to  show  for  it;  a  few 
hundred  dollars  would  replace  the  fixtures  and  equipment  of  most  of  them.1 

The  discreditable  showing  made  by  our  commercial  medical  schools  must  not, 
however,  be  permitted  to  obscure  the  fact  that  we  have  at  this  date  perhaps  thirty 
institutions  well  equipped  to  teach  the  medical  sciences  in  laboratories  usually  of 
modern  construction,  invariably  of  modern  equipment.  Twenty  years  ago  we  had  not 
one.  Our  immediate  problem  has  therefore  two  aspects :  on  the  one  hand,  to  strengthen 
these  institutions,  increasing  their  number  only  as  actual  need  requires;  on  the 
other,  with  all  the  force  that  law  and  public  opinion  can  wield  to  crush  out  the 
mercenary  concerns  that  trade  on  ignorance  and  disease. 


*In  a  few  places  there  is  a  considerable  investment:  Atlanta  College  of  Physicians  and  Surgeons, 
Atlanta  School  of  Medicine,  the  two  Richmond  schools,  for  example.  See  for  detailed  discussion, 
chapter  viii. 


COMPARATIVE  SCHEDULE,  FIRST  AND  SECOND  YEARS 
SHOWING  BEARING  OF  ENTRANCE  REQUIREMENT  ON  CURRICULUM* 

FIRST  YKAR 


WETTERN  RESERVE  UNIVERSITY 
Si  weeks  per  year 
(College  basis) 

NEW  YORE  UNIVERSITY 
32  weeks  per  year 
(Four-year  high  school  basis) 

M  miri  i  I'll  lit  i  RI  ;u-  AI.  COLLEGE 

82  weeks  per  year 
(High  school  equivalent  basis) 

UNIVERSITY  OF  ALABAMA 
28  weeks  per  year 
(Nominal  requirement) 

Anatomy 

Did. 

Lab. 

Anatomy 

Hrs. 

Anatomy 

Hrs. 

Anatomy 

Hrs. 

Comparative  anatomy 

24 

48 

Lectures  &  recitations 

96 

Lectures 

96 

Lectures 

56 

Descriptive  anatomy 

84 

Demonstrations 

96 

Demonstrations 

96 

Recitations 

66 

Splanchnology 

32 

Practical  work 

360 

Recitations 

32 

Comparative  osteology 

120 

Neurology 

7  '  ** 

Histology   and  Embryo- 

Dissections 

98-144 

Practical  anatomy  ' 

144 

Dissections 

216 

logy 

Histology    and   Embryo- 

(all practical) 

Microscopical  tech- 

Laboratory work 

128 

logy 

Inorganic  Chemistry 

nique 

16 

Lectures    and     recita- 

Didactic 

64 

Chemical  physics 

112 

Histology 

24 

32 

tions 

64 

Laboratory 

96 

Chemical  laboratory 

168 

Microscopical  anatomy 

40 

80 

Physiology 

Physiology 

Physiology 

Embryology 

40 

80 

Lectures 

48 

Didactic 

96 

(none  in  first  year) 

Physiology  and  Bio-che- 
mistry 
Experimental     physio- 
logy 
Bio-chemistry 
Organic  chemistry 

16 
16 
64 

64 
64 
112 

Recitations 
Chemistry  and  Physics 
Lectures 
Inorganic     chemis-") 
try(%)                    1 
Organic   chemistry  j 

32 

96 

Laboratory 
Chemistry 
Didactic 
Laboratory 
General  Pathology 
Didactic 

128 

160 
96 

64 

Physiological  Chemistry 
(part  practical) 
Biology,  Embryology.  <£ 
Histology 
Laboratory  work 
Pharmacy 

22 

196 

Recitations 

32 

Hygiene 

Didactic 

28 

Laboratory  work 

112 

Lectures 

32 

Bacteriology 

Recitations 

? 

Practical  work 

64 

Materia  Medica 

Lectures 

64 

Recitations 

? 

Pharmacy 

.Vote  page  X  says  : 
For  freshmen 

Lectures 
Laboratory 
Recitations 

32 

64 

1  2  to  5  p.m.,  6  days  per  week, 
for  8  weeks. 

Total  lecture*             138  hrs. 
Total  recitations          6i  hrs. 

Bandaging  and  Surgical 

Hours  figured  out  from  an- 
nouncement   and    the  class 

Total  laboratory 

Dressings 

schedule.  See  inspection  re- 

work                      112  hrs. 

Practical 

32 

port. 

SECOND  YEAR 


WESTERN  RESERVE  UNIVERSITY 

NEW  YORK  UNIVERSITY 

MEDICO-CHIRURGICAL  COLLEGE 

UNIVERSITY  OF  ALABAMA 

Anatomy 

Did. 

Lab. 

Anatomy 

Hrs. 

Anatomy 

Hrs. 

Anatomy 

Hrs. 

Descriptive  anatomy 

84 

Lectures    and    recita- 

Lectures 

96 

Lectures 

56 

Dissections 

144 

tions 

96 

Demonstrations 

64 

Recitations 

56 

Applied  anatomy 

64 

Demonstrations 

64 

Recitations 

32 

Practical  anatomy  * 

144 

Physiology  and  Bio-che- 

Practical work 

360 

Dissections 

216 

Chemistry 

mistry 

Physiology 

Physiology 

Lectures 

56 

Advanced    experimen- 
tal physiology 

Advanced    bio-chemis- 

§•« 

6 

106 

Lectures     and    recita- 
tions 
Practical  work 

96 
96 

Lectures 
Recitations 
Demonstrations 

64 
48 

Physiology 
Lectures    and    demon- 
strations 

86 

try 
Lectures    and    recita- 
tions 
Pathology    and  Preven- 
tive Medicine 

72 

32 

Chemistry 
Lectures 
Organic  chemistry  "j 
Physiological  chem-  ' 

iatrv 

48 

Laboratory 
Chemistry 
Didactic 
Laboratory 

48 

48 
128 

Laboratory  work  * 
Materia  Medica 
Lectures* 
Histology 

64 
28 

Bacteriology 

40 

82 

IBI.I  y 

Toxicology               ^ 

General  Pathology 

Lectures 

14 

Protoioology 

14 

28 

Recitations 

16 

Lectures 

64 

Laboratory 

112 

General  pathology  and 
pathological  histolo- 
gy 
Gross  pathological  ana- 
tomy 

76 

145 
32 

Laboratory  work 
Materia  Medica  and 
Pharmacology 
Lectures 

96 
64 

Laboratory 
Bctcteriology 
Laboratory 
Hygiene 

192 
96 

Bacteriology 
Lectures 
Laboratory 

11 
88 

Pharmacology.  Materia 
Medica  <t  Therapeutics 

Recitations 
Laboratory  work 

32 
63 

Didactic 
Laboratory 

64 
16 

Pharmacology,    toxico- 

Pathology 

Pharmacology  and 

logy,  and  prescription 

Lectures 

16 

Therapeutics 

wnting 

19 

88 

Recitations 

16 

Didactic 

96 

Experimental    pharma- 

Laboratory  work 

128 

Physical  Diagnosis:  Nor- 

codynamics 
Systematic    pharmaco- 
logy 
Physical  Diagnosis 

24 
12 

60 

6 
24 

Lantern  demonstration 
Elementary  Clinic 
Physical  diagnosis 

16 
30 

mal 
Practical 
Physical  Diagnosis:  Pa- 
thological 

64 

Minor  Surgery  and  Ban- 
daging 

30 

Practical  work 

Ptinix 

16 

Lectures 
Demonstrations 

82 

Surgical  Recitations 

60 

Lrlllllt. 

32 

General     Etiology    and 

Symptomatology 

Lectures 

32 

Surgical  Pathology 
Didactic 

16 

1  S  to  6  p.m.,  6  days  per  week, 
for  8  weeks. 

Laboratory 

82 

>  8  weeks  of  8  hours  per  week 

Surgical  Fevers  and  In- 

(i periods  per  week). 

flammations 

»  Only  one  hour  (lecture)  per 

Lectures 

16 

week.  See  schedule. 

*  Creditable  representatives  have  been  selected  in  each  instance. 


CHAPTER  VI 

THE  COURSE  OF  STUDY 
THE  HOSPITAL  AND  THE  MEDICAL  SCHOOL 

THE  THIRD  AND  FOURTH  YEARS  (A) 

LET  us  make  an  inventory  of  the  presumptive  acquirements  of  the  well  trained  medi- 
cal student  at  the  threshold  of  his  third  year.  He  knows  the  normal  structure  of  the 
human  body,  the  normal  composition  of  the  bodily  fluids,  the  normal  functioning 
of  tissues  and  organs,  the  physiological  action  of  ordinary  drugs,  the  main  depar- 
tures from  normal  structure,  and  in  a  limited  fashion  the  significance  of  such  de- 
partures both  to  the  organs  and  tissues  immediately  involved  and  to  the  general 
economy  of  the  organism.  He  will  have  had  his  first  lessons  in  physical  diagnosis, 
learning,  perhaps  in  the  class-room  through  examination  of  his  fellow  students,  the 
use  of  the  stethoscope,  the  arts  of  palpation,  auscultation,  and  percussion,  accus- 
toming his  ear  to  the  normal  sounds,  his  fingers  to  the  normal  "feel,"  of  the  chest 
and  abdomen  in  health.  His  studies  in  pathology  will  have  introduced  him  further 
to  the  essential  clinical  terminology,  obviating  the  necessity  of  a  separate  detached 
course  in  "elementary  medicine."1 

It  remains,  then,  in  the  first  place  to  teach  the  student  how  to  get  from  the  di- 
rect study  of  the  patient  himself  whatsoever  data  remain  to  be  collected.  He  will 
then  possess  two  sets  of  facts :  one  in  a  way  indirectly  obtained,  through  microscopic 
or  other  study  of  excretions,  secretions,  tissues,  etc. ;  the  other  set  procured  directly 
at  the  bedside.  He  must  learn  the  art  of  combining  them ;  he  must  see  them  together 
as  the  total  picture  of  the  situation  with  which  he  is  called  on  to  deal.  Upon  this 
inductive  process  all  intelligent  therapeutic  procedure  is  based :  hence  his  final  task 
— to  learn  through  an  extension  of  the  elementary  discipline  that  began  in  the  phar- 
macological laboratory,  the  therapeutic  measures  calculated  to  meet  the  more  or  less 
precisely  ascertained  and  inferred  conditions,  responsible  for  the  disturbance  he  is 
trying  to  quell. 

A  somewhat  absurd  controversy  has  at  times  raged  as  to  which  is  of  the  higher 
scientific  quality  or  diagnostic  value — the  laboratory  disclosures  or  the  bedside  ob- 
servations. Occasionally  champions  of  the  laboratory  prejudge  the  issue  by  calling 
pathology  a  real  or  pure  or  more  or  less  accurate  science,  as  against  the  presumably 
unreal  or  impure  or  inaccurate  data  secured  from  the  patient  himself.  It  becomes 

1The  place  of  pathology  in  the  American  medical  curriculum — if  the  instruction  takes  advantage  of 
it — saves  us  from  the  difficulty  encountered  in  Germany,  where  pathology  and  clinical  medicine  be- 
gin together.  "According  to  current  use  the  study  of  general  pathology  and  pathological  anatomy 
begin  simultaneously  with  attendance  on  the  clinic.  For  that  reason  the  first  semester  of  the  clinic  is 
of  very  slight  value.  .  .  .  We  ought  first  to  procure  for  the  student  clear  pathological  conceptions ; 
only  then  will  it  be  easy  for  him  to  follow  the  clinical  instruction  intelligently  and  profitably.  I  con- 
sider it  absolutely  necessary  that  the  instruction  in  general  pathology  and  pathological  anatomy 
should  precede  the  clinic."  Von  Striimpell,  loc.  cit.,  pp.  16, 17. 


92  MEDICAL  EDUCATION 

a  serious  question  of  professional  etiquette,  who  should  speak  first  or  loudest, — the 
pathologist,  armed  with  his  microscope,  or  the  clinician,  brandishing  his  stetho- 
scope. To  parallel  the  dispute,  one  must  go  back  to  the  two  knights  who,  meeting 
at  a  cross-road,  disputed  at  the  hazard  of  their  lives  as  to  the  color  of  a  shield  which, 
as  neither  had  stopped  to  reflect,  had  two  sides.  It  is  as  profitable  to  discuss  which 
was  the  right  side  of  the  shield  as  to  raise  the  question  of  precedence  between  the 
laboratory  and  the  bedside.  Both  supply  indispensable  data  of  coordinate  impor- 
tance. The  central  fact  may  be  disclosed  now  by  one,  now  by  the  other,  but  in  either 
case  it  must  be  interpreted  in  the  light  of  all  other  pertinent  facts  in  hand.  The 
scientific  character  of  the  procedure  depends  not  on  where  or  by  what  means  facts 
are  procured,  but  altogether  on  the  degree  of  caution  and  thoroughness  with  which 
observations  are  made,  inferences  drawn,  and  results  heeded.  The  essence  of  science 
is  method, — the  painstaking  collection  of  all  relevant  data,  the  severe  effort  to  read 
their  significance  in  connection.  These  objects  are  promoted  in  some  directions  by 
the  laboratory  appliances  that  eke  out  our  defective  senses;  even  so,  however,  we  do 
not  escape  or  rise  superior  to  these  same  senses;  for  with  them  we  use  the  imple- 
ments in  question.  Whatsoever,  then,  the  senses  actually  ascertain,  pertinent  to  the 
matter  in  hand,  is  scientific  datum.  The  way  to  be  unscientific  is  to  be  partial, — 
whether  to  the  laboratory  or  to  the  hospital,  it  matters  not.  The  test  of  a  good 
education  in  medicine  is  the  thorough  interpenetration  of  both  standpoints  in  their 
product,  the  young  graduate. 

If,  then,  a  laboratory  is  a  place  constructed  for  the  express  purpose  of  facilitating 
the  collection  of  data  bearing  on  definite  problems  and  the  initiation  of  practical 
measures  looking  to  their  solution,  the  hospital  and  the  dispensary  are  laboratories 
in  the  strictest  sense  of  the  term.  And  just  as  it  makes  no  difference  to  science 
whether  usable  data  be  obtained  from  a  slide  beneath  a  microscope  or  from  a  sick 
man  stretched  out  on  a  cot,  so  the  precise  nature  of  the  act  or  experiment  is  equally 
immaterial:  it  matters  not  in  the  slightest,  from  the  standpoint  of  scientific  logic, 
whether  the  step  take  the  form  of  administering  a  dose  of  calomel,  operating  for  ap- 
pendicitis, or  stimulating  a  particular  convolution  of  a  frog's  brain  with  an  electric 
current.  The  logical  position  is  in  all  three  cases  identical.  In  each  a  supposition, — 
whether  expressed  or  implied,  whether  called  theory  or  diagnosis, — based  on  suppos- 
edly adequate  observation,  submits  itself  to  the  test  of  an  experiment.  If  proper 
weight  has  been  given  to  correct  and  sufficient  facts,  the  experiment  wins ;  otherwise 
not,  and  a  second  effort,  profiting  by  previous  failure,  is  demanded.  The  practising 
physician  and  the  "theoretical"  scientist  are  thus  engaged  in  doing  the  same  sort  of 
thing,  even  while  one  is  seeking  to  correct  Mr.  Smith's  digestive  aberration  and  the 
other  to  localize  the  cerebral  functions  of  the  frog. 

Certain  conclusions  as  to  clinical  teaching  follow.  The  student  is  to  collect  and 
evaluate  facts.  The  facts  are  locked  up  in  the  patient.  To  the  patient,  therefore,  he  must 
go.  Waiving  the  personal  factor,  always  important,  that  method  of  clinical  teaching 


HOSPITAL  AND  MEDICAL  SCHOOL  93 

will  be  excellent  which  brings  the  student  into  close  and  active  relation  with  the 
patient:  close,  by  removing  all  hindrance  to  immediate  investigation;  active,  in  the 
sense,  not  merely  of  offering  opportunities,  but  of  imposing  responsibilities. 

Clinical  teaching  has  had  substantially  the  same  history  as  anatomical  teaching. 
It  was  first  didactic :  the  student  was  told  what  he  would  find  and  what  he  should  do 
when  he  found  it.1  It  was  next  demonstrative:  things  were  pointed  out  in  the  amphi- 
theater or  the  wards,  those  who  got  the  front  seats8  seeing  them  more  or  less  well. 
Latterly  it  has  become  scientific:  the  student  brings  his  own  faculties  into  play  at 
close  range, — gathering  his  own  data,  making  his  own  construction,  proposing  his 
own  course,  and  taking  the  consequences  when  the  instructor  who  has  worked  through 
exactly  the  same  process  calls  him  to  account:  the  instructor,  no  longer  a  fountain 
pouring  forth  a  full  stream  of  knowledge,  nor  a  showman  exhibiting  marvelous 
sights,  but  by  turns  an  aid  or  an  antagonist  in  a  strenuous  contest  with  disease. 

The  backbone  of  the  structure  is  the  clinic  in  internal  medicine.3  This  central  fact 
cannot  in  America  be  too  strongly  emphasized.  The  sufficiency  of  the  school's  clinical 
resources  depends  at  bottom  on  its  medical  clinic;  the  value  of  its  training  depends 
on  the  systematic  thoroughness  with  which  it  is  in  position  to  use  an  adequate  sup- 
ply of  medical  cases.  To  sample  a  school  on  its  clinical  side,  one  makes  in  the  first 
place  straight  for  its  medical  clinic,  seeking  to  learn  the  number  of  patients  available 
for  teaching,  the  variety  of  conditions  which  they  illustrate,  and  the  hospital  regu- 

1The  reader  must  not  suppose,  however,  that  this  method  of  teaching  or  practising  medicine  is  ex- 
tinct. The  following  is  quoted  from  the  Chicago  Night  University  Bulletin,  vol.  iii.,  no.  24,  p.  169 : 

"A  young  married  man,  wife  and  babe  recently  returned  from  Arkansas.  They  were  all  loaded 
with  so-called  malaria.  .  .  .  The  old  mother  came  in  to  tell  me  of  the  cases  and  get  some  'chill  medi- 
cine.' She  said  they  were  all  chilling  three  times  a  day.  ...  I  sent  the  little  tot  ipecac  1M.  She  said 
the  mother  chilled  every  morning  about  ten  o'clock,  and  that  during  the  chill  she  had  a  very  severe 
cough  which  hurt  her  right  side.  ...  I  sent  the  mother  bryonia  200.  She  said  the  husband  and  father 
chilled  at  various  times.  Great  thirst  during  fever,  severe  cough  before  and  during  the  chill,  with 
drenching  sweat  following  the  fever.  I  sent  nim  rhus  tox,  75M.  The  prescriptions  proved  to  be  rifle- 
shots for  the  mother  and  babe,  for  they  never  chilled  again ;  but  only  a  glancing  shot  for  the  husband. 
He  missed  his  chill  for  a  few  days,  when  it  returned  with  new  symptoms  and  more  severe  and  with 
which  no  medicine  seemed  to  correspond.  I  saw  him  then  personally.  Found  he  still  had  cough  during 
chill,  but  not  before;  that  he  wanted  to  be  covered  during  fever  just  the  same  as  during  the  chill, 
like  nux  v.  and  rhus  t. ;  he  had  other  symptoms  which  ruled  these  out.  After  tearching  several  hours 
with  repertory  in  hand,  1  decided  that  this  was  a  mixed  case  and  agreed  with  no  medicine  in  the  book. 
Hence,  following  Hahnemann's  advice,  I  gave  him  cinchona  (1M)  to  clear  up  his  case.  After  twenty- 
four  hours  he  chilled  again.  This  time  the  most  peculiar  thing  noticed  was  that  he  was  very  thirsty 
during  the  chill,  but  in  no  other  stage.  He  drank  large  quantities,  but  during  the  heat  and  sweat,  not 
a  drop.  Also  that  during  the  chill  the  coldness  was  relieved  by  the  heat  of  a  hot  stove.  He  wanted  to 
get  near  the  hot  stove.  Remembering .  .  .  that  for  a  chill  with  thirst  for  large  drinks  of  cold  water, 
and  no  thirst  in  any  other  stage,  ignatia  stands  alone,  I  gave  him  ignatia  1M.  to  be  taken  every  two 
hours  until  he  missed  his  chill — then  to  be  discontinued.  Well,  he  missed  the  next  chill  and  also  every 
one  which  has  been  due  him  from  that  day  to  this." 

8  This  method,  too,  survives  in  both  medical  and  surgical  clinics.  It  is  in  process  of  abandonment  in 
medical  teaching,  just  as  rapidly  as  proper  arrangements  for  ward  and  bedside  work  can  be  made. 
But  it  is  still  favored  by  surgeons,  despite  its  very  slight  practical  value. 

3  "For  clinical  studies  proper,  internal  medicine  forms  the  center  at  German  universities.  Medical 
education  there  follows  the  principle  that  medicine  is  a  scientific  whole ;  ...  all  its  varied  disciplines 
must  play  upon  each  other ;  and  from  this  point  of  view  internal  medicine  is  regarded  as  the  mother 
of  all  other  clinical  divisions."  W.  Lexis,  Das  Unterrichtswesen  im  Deutschen  Reich,  vol.  i.  pp.  138, 
139  (Berlin,  1904). 


94  MEDICAL  EDUCATION 

lations  in  so  far,  at  least,  as  they  determine  (1)  continuity  of  service  on  the  part  of 
the  teachers  of  medicine,  (2)  the  closeness  with  which  the  student  may  follow  the 
progress  of  individual  patients,  and  (3)  the  access  of  the  student  to  the  clinical  labora- 
tory. It  matters  much  less  what  else  a  school  has  by  way  of  clinical  opportunity  if  it 
has  this,  though,  of  course,  the  school  that  has  it  will  have  whatever  else  it  needs  too. 
The  main  point  is  that  there  is  no  substitute  for  a  good  clinic  in  internal  medicine; 
the  school  sampled  and  found  wanting  there  suffers  from  a  fatal  organic  lesion.  Ex- 
cellent didactic  instruction  is  no  compensation ;  successful  passing  of  written  state 
board  or  other  examinations  is  no  proof  that  the  school  has  managed  to  do  without. 
A  large  surgical  service  with  amphitheater  operations  every  day  in  the  week,  a  dispen- 
sary crowded  with  eye,  ear,  and  throat  cases, — these  are  all  very  well  in  their  way. 
But  one  comes  back  to  the  medical  clinic:  that  is  the  really  important  item.  Until 
practical  state  board  examinations  can  be  trusted  to  disclose  defective  school  facili- 
ties on  the  clinical  side,  it  is  thrice  important  to  scrutinize  carefully  the  situation 
of  every  medical  school  in  this  respect.  For  proper  provision  rests  at  this  moment 
on  the  conscientiousness  and  intelligence  of  medical  educators.  Thus  far  the  states 
have  not  adopted  an  examination  procedure  that  will  destroy  schools  not  able  to  do 
their  duty  in  regard  to  the  medical  clinic. 

The  student's  clinical  work  is  classified  under  four  heads:  (1)  medicine,  in  which 
pediatrics  and  infectious  diseases  may  be  included,  (2)  surgery,  (3)  obstetrics,  (4)  the 
specialties,  such  as  diseases  of  the  eye,  ear,  skin,  etc.  A  teaching  hospital  consists 
essentially  of  a  series  of  wards,  accommodating  patients  belonging  to  these  several 
departments,  each  ward  systematically  organized  with  a  permanent  staff;  of  a  clinical 
laboratory,  similarly  organized  and  in  close  organic  relation  with  the  wards;  and  of 
an  autopsy-room.  The  clinical  laboratory  of  the  hospital  is  not  the  same  as  the 
pathological  laboratory  of  the  medical  school.  "A  clinic  of  medicine  needs  a  labora-\ 
tory  equipped  with  apparatus  for  chemical,  physiological,  pathological,  and  bacterio- 
logical work,  not  so  completely  equipped  as  is  the  laboratory  of  these  respective 
departments  in  the  medical  school,  but  specially  equipped  for  certain  needs  of  the 
work."1  On  the  value  of  the  data  thus  obtainable  it  is  unnecessary  longer  to  dwell. 
The  clinical  laboratory  is  the  connecting  link  between  the  two  parts  of  the  medical 
school ;  and  it  must  be  immediately  accessible.  The  clinical  teacher  cannot  stop  for 
data  that  he  must  perhaps  cross  town  to  get;  the  student  responsible  for  a  parti- 
cular case  will  not  include  in  the  facts  on  the  basis  of  which  he  is  making  up  his 
mind  the  results  of  an  examination  of  blood,  sputum,  and  feces,  if  these  must  be 
transported  for  study  much  beyond  the  hospital  walls.  Nor  will  the  interne  or  the 
young  practitioner  require  the  knowledge  in  question  before  coming  to  a  conclusion, 
unless  he  has  formed  at  school  the  habit  of  so  doing.*  In  this  laboratory  a  theoreti- 

1  Henry  A.  Christian:  "The  Clinical  Laboratory,"  in  Columbia  Unwernty  Quarterly,  vol.  xi.,  no  3, 
p.  339. 

'  "We  see  the  necessity  of  laboratories  with  room  for  each  clinical  student,  each  with  his  work-place 


HOSPITAL  AND  MEDICAL  SCHOOL  95 

cal  course  in  clinical  microscopy  will  precede  the  period  when  the  student  is  speci- 
fically charged  with  responsibility  for  the  laboratory  facts  in  his  own  "cases,"  shortly 
to  be  described.  Of  equally  essential  importance  to  the  rounding  out  of  the  medical 
curriculum  is  the  autopsy -room,  where  the  wise  are  brought  to  book.  "Successful 
knowledge  of  the  infinite  Variations  of  disease  can  only  be  obtained  by  a  prolonged 
study  of  morbid  anatomy.  While  of  special  value  in  training  the  physician  in  diag- 
nosis, it  also  enables  him  to  correct  his  mistakes,  and  if  he  reads  its  lessons  aright, 
it  may  serve  to  keep  him  humble."1 

The  teaching  dispensary  follows  the  same  lines  as  the  teaching  hospital  in  respect 
to  both  organization  and  equipment,  and  must  be  constructed  with  its  pedagogical 
use  in  view.  It  consists  essentially  of  a  commodious  receiving-room,  leading  from 
which  are  separate  rooms,  sufficiently  large,  clean,  well  lighted,  each  assigned  to  a 
separate  department.  The  several  rooms  are  appropriately  equipped  with  instruments, 
apparatus,  etc.,  and  with  a  recording  system  which  enables  the  workers  to  keep  track 
of  each  patient  and  to  collate  readily  all  cases  of  the  same  general  character.  Each 
department  must  have  an  organized  teaching  staff;  the  receiving-room  must  be  in 
charge  of  a  physician,  who  will  assign  patients  to  the  departments  to  which  they 
severally  belong.  The  clinical  laboratory  must  be  at  hand  so  that  the  necessary  mi- 
croscopical examinations  can  be  made  without  loss  of  time. 

From  the  teaching  point  of  view,  the  hospital  and  the  dispensary  differ  in  certain 
respects;  certain  classes  of  cases  do  not  usually  enter  the  hospital  wards  at  all:  minor 
surgery,  trivial  medical  ailments,  numerous  afflictions  involving  eye,  ear,  nose,  throat, 
skin,  etc.  Ambulatory  patients  are  also  under  less  satisfactory  control ;  a  large  propor- 
tion never  come  a  second  time.  The  dispensary  is  therefore  excellently  adapted  to  show 
a  large  variety  of  conditions;  it  is  a  relatively  poor  place  to  watch  their  development. 
In  the  dispensary  the  student  can  become  expert  in  initial  physical  examination; 
but  only  the  hospital  wards  enable  him  to  study  progress,  to  observe  nature's  com- 
ment on  therapeutic  moves.  The  dispensary  corresponds  to  the  "office  hour," — so 
important  an  item  in  the  physician's  early  progress;  the  hospital  ward  represents  the 
sick-room.  Clearly,  a  huge  dispensary  does  not  wholly  offset  a  defective  hospital. 

Between  dispensary  and  hospital,  clinical  instruction  in  the  third  and  fourth  years 
is  variously  apportioned.2  But  apportioned  they  must  be ;  for  the  mingling  of  third 

properly  equipped.  In  building  this  well  arranged  laboratory  the  university  has  by  no  means  erected 
something  superfluous.  ...  It  has  simply  met  a  positive  need.  In  putting  the  laboratories  in  such  in- 
timate relations  with  the  hospital,  and  especially  with  the  dispensaries,  it  has  provided  means  for  an  im- 
mense increase  of  its  facilities.  It  is  a  place  for  practice,  for  doing  as  an  undergraduate  the  things  that 
must  be  done  afterward  in  carrying  on  the  profession  of  medicine."  George  Dock,  "Address  at  Open- 
ing of  Clinical  Laboratory  of  the  University  of  Pennsylvania  Hospital,'  University  of  Pennsylvania 
Medical  Bulletin,  Aug.,  1909  (slightly  abridged). 
1  Osier,  loc.  cit.,  p.  144. 

8  Taking  a  four-year  curriculum  of  4100  hours  as  a  basis,  the  pattern  curriculum  worked  out  by 
the  Council  on  Education  of  the  American  Medical  Association  allowed  1970  hours  to  anatomy,  phy- 
siology, physiological  chemistry,  pathology,  bacteriology,  pharmacology,  toxicology,  and  therapeutics, 
—  or,  in  other  words,  the  scientific  subjects  included  in  the  first  two  years.  Clinical  instruction  gets 
2130  hours,  distributed  as  follows: 


96  MEDICAL  EDUCATION 

and  fourth  year  students  in  clinical  work  is  severely  reprehensible, — an  infallible  in- 
dication of  deficient  clinical  material,  imperfect  teaching  organization,  or  of  both. 
As  for  the  rest,  there  can  be  no  fixed  rule.  Important,  mainly,  is  it  that  the  student 
be  brought  into  immediate  and  increasingly  responsible  contact  with  the  disordered 
machine. 

Let  us  consider  briefly  the  dispensary  first.  The  classes  are  divided  into  small 
rotating  sections,  each  with  regular  appointments  in  every  one  of  the  dispensary 
departments.  The  sections,  in  charge  of  separate  instructors,  should  not  contain  more 
than  ten  students  apiece — rather  fewer  would  be  even  better.  The  student  is  trained 
at  once  to  take  the  patient's  history,  to  make  the  physical  examination,  to  examine 
blood,  sputum,  etc.,  and  on  the  basis  of  all  the  facts  thus  amassed  to  make  a  diag- 
nosis and  suggest  a  course  of  treatment.  The  instructor  stands  by,  to  correct  and  to 
stimulate  by  question,  criticism,  or  suggestion.  Everything  is  a  matter  of  record, 
and  the  student's  work  is  thus  part  of,  in  a  sense  the  basis  of,  the  complete  dispen- 
sary records.  In  the  surgical  out-patient  department,  bandaging,  stitching  up  a  wound, 
administering  anesthetics,  quickly  fall  to  his  lot.  Schools  favorably  located  in  large 
cities  are  able  to  develop  considerable  out-patient  obstetrical  work.  Thus  the  student 
not  only  amplifies  his  experience,  but  learns  to  combat  the  conditions  under  which 
he  will  subsequently  be  called  upon  to  work.  He  should,  of  course,  in  justice  to  his 
charge,  be  accompanied  by  an  instructor,  though  in  the  weaker  schools  this  is  by  no 
means  always  arranged.  Even  so,  however,  out-patient  obstetrical  work,  though  an 
experience,  is  not  a  discipline:  it  does  not  dispense  with  the  necessity  of  careful 
training  in  method  under  ideal  hospital  conditions.  The  young  physician  will  never 
learn  technique  and  the  importance  of  technique  properly  except  in  the  maternity 
hospital;  having  learned  them  there,  his  problem  in  practice  is  to  secure  the  essen- 
tials even  amidst  the  most  unpromising  environment.  In  certain  of  the  specialties — 
dermatology,  ophthalmology — the  bulk  of  the  direct  instruction  received  is  in  the 
dispensary  service.  To  some  extent,  of  course,  the  conditions  observed  in  them  come 
under  repeated  observation  in  the  medical  clinics  of  both  third  and  fourth  years ; 
full  mastery  of  a  specialty  belongs  of  course  to  the  postgraduate  years.  But  the  stu- 
dent must  be  sufficiently  at  home  to  help  himself  in  emergencies  and  to  know  when 
and  whence  to  seek  further  assistance. 

The  fourth  year  is  spent  in  the  hospital  under  precisely  the  same  conditions.  The 
class  is  again  broken  up  into  small  groups.  Each  student  gets  by  assignment  a  suc- 
cession of  cases,  for  a  full  report  upon  each  of  which  he  is  responsible;  he  must 
take  the  history,  conduct  the  physical  examination,  do  the  microscopical  and  other 
clinical  laboratory  work,  propound  a  diagnosis,  suggest  the  treatment.  For  this 

Medicine  (including  clinical  pathology  and  pediatrics),  800  hours 
Surgery  OM     " 

Obstetrics  and  gynecology  240     ' 

DiMMM  of  the  eye,  ear,  nose,  and  throat  140     * 

Dermatology  and  syphilis  00      * 

Hygiene  and  medical  jurisprudence  120      " 


HOSPITAL  AND  MEDICAL  SCHOOL  97 

purpose  he  has  easy  access  to  the  hospital  wards.  His  "beds"  are  under  his  con- 
tinuous observation  from  the  day  his  "patient"  is  admitted  until  the  day  of  dis- 
charge; or,  in  the  event  of  death,  he  and  the  physician  ultimately  responsible  for 
the  steps  taken  in  treatment  repair  with  others  to  the  autopsy-room  to  bring  their 
knowledge  to  the  test,  as  Thomas  Bond  quaintly  phrased  it.  Meanwhile,  the  clinical 
teaching  has  closely  followed  the  development  of  the  case.  At  brief  and  regular 
intervals  its  status  is  reviewed.  All  other  members  of  his  group,  and  the  patient 
too,  are  at  hand  when  the  student  presents  his  report,  which  forms,  once  more, 
part  of  the  permanent  record  of  the  case.  At  every  point  he  has  been  checked  up; 
the  instructor  in  charge  of  the  clinical  laboratory  inspects  and  verifies  his  work 
there;  the  clinical  instructor,  here.  The  latter  officer  reviews  everything,  pointing 
out  omissions,  errors,  misinterpretation.  The  student  has  always  an  appeal.  He  may 
on  second  trial  convince  himself  of  his  blunder.  He  may,  however,  be  only  the  more 
convinced  he  was  right,  whereupon  another  look  may  persuade  the  instructor  that 
it  is  he  who  errs !  Subject  to  this  control,  complete,  of  course,  from  the  standpoint 
of  treatment  followed,  the  student  is  a  physician  practising  the  technique  which,  it 
is  to  be  hoped,  may  become  his  fixed  professional  habit ;  learning  through  experience, 
as  indeed  he  will  continue  to  learn,  long  after  he  has  left  school, — a  controlled, 
systematized,  criticized  experience,  however,  not  the  blundering,  helpless  **  experi- 
ence" upon  which  the  didactically  or  demonstratively  taught  student  of  medicine 
has  hitherto  relied  for  a  slow  and  costly  initiation  into  the  art  of  medicine. 

In  the  surgical  ward,  a  similar  arrangement  is  feasible.  The  student  assists  in  the 
operation  of  his  own  "case"  and  follows  the  after-treatment.  Obstetrical  training 
pursues  analogous  lines.  After  preliminary  drill  with  the  manikin,  the  student  first 
assists,  then  has  charge  under  an  instructor,  of  the  cases  in  question.  He  learns 
in  the  hospital  wards  the  proper  care  and  manipulations,  his  experience  supple- 
mented, as  we  have  pointed  out,  by  a  regularly  organized  out-patient  department, 
which  brings  him  in  the  home,  in  contact  with  the  trying  conditions  that  he  will 
encounter  in  practice.  Pediatrics  and  infectious  diseases  are  likewise  scheduled  and 
organized.  A  simple  method  of  rotation  carries  the  student  in  this  intimate  and 
responsible  fashion  through  all  departments  in  the  course  of  two  years. 

Demonstrative  teaching  necessarily  accompanies  the  method  described:  in  each 
group  of  five,  only  one  student  personally  explores  each  case.1  At  the  next  bed  a  new 
protagonist  comes  to  the  front ;  and  so  on,  until  each  man  has  had  his  turn.  Always, 
then,  four  of  the  five  men  are  getting  demonstrative  teaching,  though  of  a  somewhat 
intimate  kind.  The  demonstrative  method  must,  for  lack  of  time,  also  be  more  widely 
employed :  large  sections  are  sent  on  ward  rounds,  in  the  course  of  which  the  instruc- 
tor demonstrates  the  salient  features  of  a  considerable  number  and  variety  of  cases. 
The  defects  of  the  method  are  manifest:  it  is  not  sufficiently  direct,  accountable,  and 
systematic  to  constitute  the  sole  lasting  discipline.  At  best,  the  student  becomes  in 
1  In  some  schools  two  students  have  charge  of  each  case,  the  principle  remaining  the  same. 


98  MEDICAL  EDUCATION 

this  way  familiar  with  conditions  singly  and  in  their  combination  and  interconnec- 
tion. He  gets  cross-sections  of  disease — a  most  important  experience,  but,  once  more, 
not  the  same  thing  as  the  continuous  observation  of  the  developing  disease  process 
and  the  influence  thereon  from  day  to  day  of  whatever  therapeutic  procedure  is 
adopted.  In  the  same  way,  an  instructor  in  physics  might  take  his  students  through 
a  large  laboratory,  showing  them  how  electrical  attraction  or  some  other  single  factor 
produces  a  particular  type  of  effect  in  each  of  a  dozen  different  experiments, — a  most 
valuable  method  to  impress  upon  them  the  specific  tendency  or  effect  of  the  force 
under  discussion ;  but  no  substitute  for  experiments  performed  by  the  student  him- 
self from  beginning  to  end,  in  which  electrical  attraction  and  much  besides  come  into 
play.  Under  any  but  the  most  vigorous  teaching,  the  demonstrative  method  may 
fail  to  stimulate  sufficiently:  the  student  looks  and  listens, — a  passive  attitude  that 
may  relapse  into  something  more  deeply  negative.  Finally,  the  ease  with  which  an 
expert  passes  from  case  to  case,  the  necessity  of  confining  attention  to  decisive  fea- 
tures which  he  selects,  may,  if  not  elsewhere  corrected,  tend  to  encourage  the  super- 
ficial examination  and  the  hasty  conclusions  with  which  current  practice  may  be 
justly  reproached.  Outside  the  wards  there  is  a  narrowly  limited  use  for  demonstra- 
tive instruction  in  the  class-room  or  small  amphitheater,  where  groups  of  cases  can 
conveniently  be  shown ;  but  the  value  of  demonstration  increases  apace,  as  it  ap- 
proaches the  intimacy  of  the  individual  experiment.  Remoteness  is  quickly  fatal. 
"The  larger  the  circle  of  listeners,  the  more  difficult  for  the  teacher  to  hold  the  in- 
terest of  them  all;  as  soon  as  those  sitting  some  distance  off  no  longer  see  and  hear 
exactly  what  is  to  be  seen  and  heard,  their  thoughts  run  wild,  they  lose  the  logical 
thread  of  the  diagnostic  process.'11  This  is  especially  true  of  spectacular  amphitheater 
surgery,  which  is  of  meager  educational  value,  though  as  a  rule  prominently  exploited. 

Other  methods  have  their  uses  also;  even  the  didactic  lecture  may  not  perhaps  be 
wholly  dispensed  with.  Case  work  is  discrete;  students  rarely  possess  sufficient  gen- 
eralizing power  to  redeem  it  from  scrappiness.  At  the  bedside  not  much  time  is  avail- 
able for  comprehensive  or  philosophical  elucidation.  The  lecture — hugging  as  closely 
as  may  be  the  solid  ground  of  experienced  fact — may  therefore  from  time  to  time 
be  employed  to  summarize,  amplify,  and  systematize.  In  time,  the  student's  sense  of 
reality  will  be  sufficiently  pronounced  to  enable  him  to  grasp  a  rare  condition  that  he 
knows  only  through  exposition.  The  wards  may  have  failed  to  supply  an  example. 
But  however  used  —  whether  to  classify  first-hand  knowledge  or  to  fill  up  a  gap — 
the  didactic  lecture  would  appear  to  be  pedagogically  sound  only  at  a  relatively  late 
stage  of  the  student's  discipline.  It  has  no  right  to  forestall  experience,  filling  the 
student  with  ill  comprehended  notions  of  what  he  is  going  some  time  to  perceive. 

Some  ingenious  Harvard  men,  profiting  by  the  experience  of  the  Harvard  law 
school,  have  evolved  an  effective  discipline  in  the  art  of  inference.  Just  as  a  prelimi- 
nary course  in  physical  diagnosis,  teaching  the  student  how  to  gather  his  facts,  is 

1  Von  Stniinpcll,  loc.  eit.,  p.  23. 


HOSPITAL  AND  MEDICAL  SCHOOL  99 

valuable,  so,  it  is  urged,  a  formal  training  in  the  inductive  handling  of  ascertained 
data  may  be  of  use  to  students  whose  logical  habit  has  been  none  too  strictly  formed. 
"Let  us  assume  such  and  such  data :  what  do  they  mean  ?  What  would  you  do  ?""  This 
is  the  essence  of  the  case  method, — a  method,  by  the  way,  excellently  adapted  to  class 
use,  calculated  there  to  develop  the  friction,  competition,  and  interest  which  are 
powerful  pedagogical  stimulants.  It  is,  moreover,  economical,  for  it  brings  consider- 
able numbers  in  touch  with  fertile  teachers,  at  a  minimum  expenditure  of  time  and 
energy. 

The  class  in  medicine  has  another  use:  it  may  be  made  the  means  of  training  stu- 
dents to  use  the  " literature;"  once  more,  of  course,  only  by  way  of  amplifying  an 
actual  sense- experience.  One's  own  experience  always  falls  short;  yet  without  a 
very  vivid  realization  of  just  what  one's  own  experience  is  and  means,  one  is  in  no 
position  to  use  a  vicarious  experience  intelligently.  The  careful  taking  and  keeping 
of  records  is  in  the  first  instance  the  means  of  clarifying  the  student's  own  experience; 
the  instructor's  comments  raise  the  questions  which  he  may  profitably  investigate  in 
the  literature.  The  case  record  in  full  and  an  abstract  of  important  publications  on 
the  same  subject  may  well  fill  a  regularly  appointed  hour  given  to  informal  confer- 
ence and  discussion.  The  student  will  thus  get  into  the  way  of  reading  substantial 
journals  and  "running  down"  literature  in  the  course  of  his  actual  practice. 

It  is  a  nice  question  as  to  how  the  student's  time  in  the  third  and  fourth  year  is 
to  be  apportioned  between  patient  work,  ward  work,  demonstrative  and  class  exer- 
cises, and  didactic  lectures.  The  number  of  hours  is  itself  necessarily  elastic :  for  if 
the  hospital  is  a  laboratory,  it  is  open  at  all  hours,  and,  subject  to  the  limitations 
fixed  in  each  case  by  the  condition  of  the  patient,  the  wards  may  be  used  by  stu- 
dents, even  though  no  teaching  is  going  on.  The  principle  upon  which  division  may 
be  made  has  been,  however,  very  clearly  stated  by  Cabot  and  Locke.  "Learning 
medicine  is  not  fundamentally  different  from  learning  anything  else.  If  one  had  one 
hundred  hours  in  which  to  learn  to  ride  a  horse  or  to  speak  in  public,  one  might 
profitably  spend  perhaps  an  hour  (in  divided  doses)  in  being  told  how  to  do  it,  four 
hours  in  watching  a  teacher  do  it,  and  the  remaining  ninety-five  hours  in  practice, 
at  first  with  close  supervision,  later  under  general  oversight."1 

In  what  relation  is  the  medical  school  to  stand  to  its  hospital  if  the  methods 
above  described  are  to  be  instituted?  Exactly  the  relation  which  it  occupies  to  its 
laboratories  generally.  One  sort  of  laboratory  may  as  well  be  borrowed  as  another. 
The  university  professor  of  physics  can  teach  his  subject  in  borrowed  quarters  quite 
as  well  as  the  university  professor  of  clinical  medicine.  Courtesy  and  comity  will  go 
as  far  in  one  case  as  in  the  other :  in  both  it  keeps  teaching  to  the  demonstrative 
basis, — or  worse,  according  to  the  limitations  prescribed.  The  student  can  never 
be  part  of  the  organization  in  a  hospital  in  which  he  is  present  on  sufferance.  A 

1<lThe  Organization  of  a  Department  of  Clinical  Medicine,"  by  Richard  C.  Cabot  and  Edwin  A. 
Locke,  p.  9.  (Reprinted  from  Boston  Med.  and  Surg.  Journal,  Oct.  19,  1905.) 


100  MEDICAL  EDUCATION 

teaching  hospital  will  not  be  controlled  by  the  faculty  in  term-time  only;  it  will  not 
be  a  hospital  in  which  any  physician  may  attend  his  own  cases.  Centralized  admin- 
istration of  wards,  dispensary,  and  laboratories,  as  organically  one,  requires  that  the 
school  relationship  be  continuous  and  unhampered.  The  patient's  welfare  is  ever  the 
first  consideration;  we  shall  see  that  it  is  promoted,  not  prejudiced,  by  the  right 
kind  of  teaching.  The  superintendent  must  be  intelligent  and  sympathetic ;  the  fac- 
ulty must  be  the  staff,  solely  and  alone,  year  in,  year  out.  There  will  be  one  head  to 
each  department — a  chief,  with  such  aides  as  the  size  of  the  service,  the  degree  of 
differentiation  feasible,  the  number  of  students,  suggest.  The  professor  of  medicine 
in  the  school  is  physician-in-chief  to  the  hospital;  the  professor  of  surgery  is  surgeon- 
in-chief;  the  professor  of  pathology  is  hospital  pathologist.  School  and  hospital  are 
thus  interlocked.  Assistants,  internes,  students,  collaborate  in  amassing  data  and 
compiling  case  records.  The  student  is  part  of  the  hospital  machine ;  he  can  do  no 
harm  while  all  the  pressure  of  its  efficient  and  intelligent  routine  is  used  to  train 
him  in  thorough  and  orderly  method.  There  comes  a  time,  indeed,  in  a  physician's 
development  when  any  opportunity  to  look  on  is  helpful ;  but  only  after  he  is  trained : 
his  training  he  cannot  get  by  looking  on.  That  he  gets  by  doing:  in  the  medical 
school  if  he  can;  otherwise,  in  his  early  practice,  which  in  that  case  furnishes  his 
clinical  schooling  without  a  teacher  to  keep  the  beginner  straight  and  to  safeguard 
the  welfare  of  the  patient. 

The  relationship  here  indicated  has  not  thus  far,  as  a  rule,  proved  attainable  in 
the  United  States  except  through  the  separate  creation  of  a  university  hospital.  In 
Germany,  where  hospitals  and  universities  belong  to  the  same  government,  our 
problem  does  not  arise;  nor  in  England  and  Scotland,  where  hospital  and  school 
have  grown  up  together.  In  the  United  States — outside,  once  more,  the  few  fortunate 
institutions  like  Johns  Hopkins,  the  University  of  Virginia,  and  the  University  of 
Michigan — the  schools  developed  as  detached  faculties,  craving,  after  a  while,  some 
sort  of  demonstrative  teaching  privilege  in  hospitals  conducted  by  the  municipality 
or  by  philanthropic  associations  as  temporary  homes  for  sick  people.  Political  reasons 
in  the  former  instance,  prudential  in  the  latter,  generally  forbade  an  exclusive  re- 
lationship. Lack  of  funds  interfered  with  the  establishment  of  laboratories;  compe- 
tition between  rival  schools  required  that  privileges  be  both  divided  and  restricted; 
finally,  the  inferiority  of  the  students  was  an  insuperable  obstacle  to  any  teaching 
method  which  sought  to  use  them  in  the  wards  in  any  responsible  way  whatsoever. 
More  intelligent  conceptions  are  becoming  current:  the  student  body  improves; 
competition  yields  here  and  there  to  consolidation.  Even  so,  there  remain  generally 
insuperable  difficulties:  purely  philanthropic  enterprises  must  be  economically  con- 
ducted, and  they  cannot  in  most  places  play  favorites  in  the  local  profession.  Ade- 
quate equipment,  effective  organization,  and  continuous  staff  service  are  therefore 
as  a  rule  improbable.  The  hospital  and  dispensary  which  the  medical  school  must 
provide  to  obtain  these  conditions  need  be  large  enough  to  furnish  only  the  funda- 


HOSPITAL  AND  MEDICAL  SCHOOL  101 

mental  training  of  the  student  body  in  method  and  to  afford  the  various  members 
of  the  faculty  their  own  several  workshops.  Each  department  needs  beds  and  accom- 
panying facilities  enough  to  care  for  typical  clinical  cases  for  instruction  and  for 
such  other  cases  as  the  teacher  himself  wants  to  study  under  the  most  favorable 
conditions.  Beyond  this  requirement,  other  local  hospitals  may  well  provide  supple- 
mentary illustrative  material,  particularly  for  advanced  students.  Once  more,  a  long 
list  of  such  supplementary  opportunities  scattered  through  the  town  is  no  substitute 
for  the  fundamental  teaching  and  working  hospital,  on  the  existence  of  which  even 
a  fairly  satisfactory  use  of  additional  and  imperfectly  controlled  clinical  material 
depends.  Indeed,  without  such  a  teaching  hospital,  the  school  cannot  even  organize 
a  clinical  faculty  in  any  proper  sense  of  the  term. 

The  control  of  the  hospital  by  the  medical  school  puts  another  face  on  its  rela- 
tions to  its  clinical  faculty.  What  would  one  think  of  an  institution  that,  requiring 
a  professor  of  physics,  began  by  seeking  some  one  who  had  his  own  laboratory  or 
had  got  leave  to  work  a  while  daily  in  a  laboratory  belonging  to  some  one  else?  That 
is  the  position  of  the  medical  school  that,  in  order  to  gain  even  limited  use  of  a  hos- 
pital ward,  has  to  cajole  a  staff  physician  with  a  professorial  title!  When  the  hospital 
belongs  to  the  medical  school,  appointments  are  made  on  the  basis  of  fitness,  emi- 
nence, skill.  A  man  is  promoted  if  he  deserves  it;  if  a  better  man  is  available  else- 
where, he  is  imported.  Opportunities  are  his  in  virtue  of  the  university's  choice :  it  is 
absurd  to  reverse  the  order.  The  men  thus  freely  selected  will  be  professors  in  the 
ordinary  acceptation  of  the  term :  they  hold  chairs  in  an  institution  resting  on  a 
collegiate  basis, — a  graduate  institution,  in  other  words.  They  will  be  simulta- 
neously teachers  and  investigators.  Non-progressive  clinical  teaching  involves  a  con- 
tradiction in  terms.  The  very  cases  which  are  exhibited  to  beginners  have  their 
unique  features.  New  problems  thus  spring  up.  Every  accepted  line  of  treatment 
leaves  something  to  be  desired.  Who  is  to  improve  matters,  if  not  your  university 
professor,  with  the  hospital  in  which  he  controls  conditions,  with  a  dozen  laboratories 
at  his  service  for  such  aid  as  he  summons,  with  a  staff  who  will  be  eyes  and  ears  and 
hands  for  him  in  his  absence?  These  conditions  exist  in  Germany,  and  clinical  science 
has  there  thriven ;  they  are  lacking  here,  and  clinical  medicine  droops  in  consequence. 
Undoubtedly,  outright  research  institutions  for  clinical  medicine  are  also  necessary, 
the  routine  of  the  clinical  teacher  cuts  into  his  time,  to  some  extent  limits  the  tasks 
he  may  essay,  for  the  knotty  problems  of  clinical  medicine  are  excessively  compli- 
cated and  difficult.  But  the  field  abounds  in  questions  for  which  the  university  hos- 
pital with  its  laboratories  is  the  right  place.  Nor  will  the  young  doctor,  for  all  his 
admirable  technique,  prove  a  progressive  practitioner,  even  to  the  extent  of  keeping 
up  his  reading,  unless  his  teachers  have  been  so  before  him. 

By  the  laboratories  connected  with  the  university  hospital  we  do  not  mean  merely 
the  fundamental  laboratories,  described  in  a  previous  chapter,  or  the  clinical  labo- 
ratory, just  mentioned:  the  former  as  such  deal  with  the  subject-matter  of  their 


102  MEDICAL  EDUCATION 

respective  sciences,  in  their  general  relations;  the  latter  is  part  of  the  routine  ma- 
chinery of  the  hospital.  To  suffice  for  clinical  investigation  the  laboratory  staff  must 
be  so  extended  as  to  place,  at  the  immediate  service  of  the  clinician,  the  experimental 
pathologist,  experimental  physiologist,  and  clinical  chemist  in  position  to  bring  all 
the  resources  of  their  several  departments  to  bear  on  the  solution  of  concrete  clinical 
problems.  Of  these  branches,  experimental  pathology  and  physiology  have  already 
won  recognition ;  the  next  step  in  progress  seems  to  lie  in  the  field  of  clinical  chemistry, 
thus  far  quite  undeveloped  in  America. 

It  follows  that  in  other  respects,  too,  the  clinical  professors  will  be  on  the  common 
university  basis:  salaried,  as  other  professors  are.  Of  course,  their  salaries  will  be  in- 
adequate, i.e.,  less  than  they  can  earn  outside, — all  academic  salaries  paid  to  the 
right  men  are.  But  there  is  no  inherent  reason  why  a  professor  of  medicine  should 
not  make  something  of  the  financial  sacrifice  that  the  professor  of  physics  makes : 
both  give  up  something — less  and  less,  let  us  hope,  as  time  goes  on  —  in  order  to 
teach  and  to  investigate.  The  clinical  teacher  should  indeed  not  arbitrarily  restrict 
his  experience:  he  may  wisely  develop — preferably  in  close  connection  with  the  hos- 
pital— a  consulting  practice,  assured  thus  that  his  time  will  not  be  sacrificed  to 
trivial  ailments.  On  the  same  basis,  other  university  facilities  are  at  the  service  of 
those  who  require  unusually  skilful  aid;  for  at  all  points  only  good  can  come  of 
educational  contact  with  unsolved  problems, — practical  or  other.  But  a  consulting 
practice — developed  in  a  professional  or  commercial,  rather  than  in  a  scientific  spirit 
— may  prove  quite  as  fatal  to  scientific  interest  as  general  practice.  University  hos- 
pitals, academic  salaries,  etc.,  make  the  conditions  in  which  clinical  medicine  may 
be  productively  cultivated.  They  do  not  create  ideals;  and  without  ideals,  super- 
abundant and  highly  paid  consultations  are  perhaps  as  demoralizing  as  superabun- 
dant low-priced  "calls."1 

The  financial  resources  at  this  moment  available  are  far  from  adequate  to  provide 
hospitals  exclusively  and  continuously  the  laboratory  of  the  clinical  departments 
of  medical  schools,  and  faculties  composed  in  the  first  place  of  scientific  teachers  of 
clinical  medicine.  Twenty-five  years  ago  as  much  would  have  been  said  in  reply  to 
a  plea  for  thirty  medical  schools  each  equipped  with  a  complete  set  of  scientific 
laboratories.  When  the  number  of  our  medical  schools  is  once  reduced  to  our  actual 
requirement,  the  sum  involved  in  properly  equipping  them  with  hospitals  will  not 
appear  impossibly  formidable.  Meanwhile,  existing  hospitals  may  well  enlarge  their 
teaching  facilities,  where  such  facilities  are  open  to  a  high-grade  student  body.  No- 
thing is  clearer  than  that  an  intimate  relation  to  medical  education  properly  carried 
on  is  to  the  advantage  of  all  concerned, — to  the  larger  public,  by  producing  better 
physicians,  to  the  patient,  by  procuring  for  him  more  competent  attention.  On  this 
point  there  is  no  room  for  doubt.  "  I  speak  after  an  experience  of  nearly  forty  years," 

»Sce,  for  example,  Graham  Lusk :"  Medical  Education,"  Journal  Amer.  Med.  Atm.,  April  17,  1909, 
pp.  1229, 1230,  and  S.  J.  MelUer,  "The  Science  ofClinical  Medicine, "  ibid.,  August H,  1909,  pp.  50&-12. 


HOSPITAL  AND  MEDICAL  SCHOOL  103 

says  Dr.  Keen,  "as  a  surgeon  to  a  half-dozen  hospitals,  and  can  confidently  say  that 
I  have  never  known  a  single  patient  injured  or  his  chances  of  recovery  lessened  by 
such  teaching.  Moreover, . . .  who  will  be  least  slovenly  and  careless  in  his  duties, 
— he  who  prescribes  in  the  solitude  of  the  sick-chamber  and  operates  with  two  or  three 
assistants  only,  or  he  whose  every  movement  is  eagerly  watched  by  hundreds  of  eyes, 
alert  to  detect  every  false  step? ...  I  always  feel  at  the  Jefferson  Hospital  as  if  I 
were  on  the  run,  with  a  pack  of  lively  dogs  at  my  heels."1  Miss  Bun  field,  after  an 
ample  experience,  looking  at  the  question  solely  from  the  standpoint  of  patient  and 
nurse,  takes  the  same  position:  "As  a  matter  of  fact,  in  a  properly  administered  hos- 
pital, medical  schools  are  a  protection  to  the  patient  rather  than  otherwise,  for  it 
usually  means  that  the  hospital  is  a  very  live  one. ...  In  teaching  hospitals,  I  think 
that  on  the  whole  patients  are  generally  better  nursed,  for  every  one  is  kept  up  to 
the  mark,  including  the  professors."2  The  committee  appointed  in  1905  to  inquire 
into  the  financial  relations  between  the  hospitals  and  the  medical  schools  of  London, 
touch  in  their  conclusions  the  point  here  in  question :  "We  find,"  they  say,  "that 
the  presence  of  a  body  of  eager  young  men  watching  the  proceedings  of  their  teacher 
has  the  tendency  to  keep  the  medical  man  on  the  alert  and  to  counteract  the  effects 
of  the  daily  routine  of  duties."3 

There  is  little  difference  of  opinion  as  to  the  necessary  size  of  a  teaching  hospital. 
Less  than  two  or  three  hundred  beds,  in  practically  continuous  occupation,  can 
hardly  supply  either  the  number  or  the  variety  of  cases  required.  It  is  held  that  a 
hospital  of  400  beds  will  support  a  medical  school  of  at  least  500  students.  It  is 
highly  important  that  the  instructor  should  have  the  material  that  he  needs  when  he 
needs  it.  The  material  must,  moreover,  be  properly  distributed:  an  abundant  clinic 
in  diseases  of  the  eye  is  no  substitute  for  defects  in  the  departments  of  internal 
medicine  and  obstetrics ;  seventy -five  cases  of  operated  appendicitis  do  nothing  to 
compensate  for  the  lack  of  typhoid,  pneumonia,  or  scarlet  fever. 

The  size  of  the  school  has,  of  course,  some  bearing  on  the  necessary  size  of  the 
hospital,  though  the  hospital  cannot  be  allowed  to  shrink  in  exactly  the  same  ratio 
as  the  number  of  students.  Because  two  hundred  beds  may  be  made  to  suffice  for  one 
hundred  students,  it  does  not  follow  that  twenty  beds  suffice  for  ten  students.  Twenty- 
five  students  require  in  general  the  same  minimum  as  one  hundred  students.  On  the 
other  hand,  it  is  fair  to  weigh  advantages  and  disadvantages  against  each  other.  A 
small  number  of  students  in  a  small  but  still  fairly  representative  and  completely 
controlled  university  hospital,  through  whose  corridors  fresh  scientific  breezes  from 
the  university  and  medical  school  laboratories  blow,  will  get  a  better  discipline  in  the 

JW.  W.  Keen:  "The  Duties  and  Responsibilities  of  the  Trustees  of  Public  Medical  Institutions," 

Transactions  Congress  Amer.  Physicians  and  Surgeons,  1903. 

2 Maud  Banfield  :  "Some  Unsettled  Questions  in  Hospital  Administration  in  the  United  States," 

Publications  of  Amer.  Acad.  Pol.  and  Soc.  Science,  no.  351,  pp.  46,  47  (slightly  abridged). 

3  Report  of  the  Committee.  Published  for  King  Edward's  Hospital  Fund  for  London,  by  George 

Barber,  93  Furnival  Street,  Holborn,  E.  C.  p.  v,  15  (B). 


104  MEDICAL  EDUCATION 

technique  of  modern  medicine  than  a  larger  body,  loosely  supervised  in  an  antiquated 
city  hospital  where  "students"  are  eyed  askance  as  interlopers.  The  defects  of  the 
former,  due  to  somewhat  circumscribed  experience,  a  hospital  year  will  quickly  re- 
deem, for  he  has,  and  knows  how  to  use,  the  tools;  the  defects  of  the  latter  will  as  a 
rule  never  be  repaired  at  all.  Such  a  hospital  year  is  in  any  event  highly  desirable. 
It  is  to  be  hoped  that  a  more  effective  and  economical  organization  of  preliminary 
education  and  a  more  intelligent  public  opinion  may  presently  make  its  exaction 
generally  feasible.1 

On  the  basis  of  the  undergraduate  instruction  described,  opportunities  for  ad- 
vanced or  graduate  instruction  must  supervene.  Such  opportunities  serve  two  quite 
different  functions.  In  the  first  place,  the  various  specialties  must  be  systematically 
and  thoroughly  developed  as  graduate  pursuits,  resting  on  a  thorough  training  and 
experience  in  general  medicine.  The  number  of  these  specialties  is  increasing,  as  more 
varied  and  more  effective  appliances  suggest  increased  differentiation, — a  safe  ten- 
dency, in  the  interest  of  efficiency,  provided  the  discipline  required  does  not  infringe 
upon  undergraduate  territory.  In  the  next  place,  to  these  postgraduate  institutions 
the  hard-run  intelligent  practitioner  in  smaller  towns  will  at  intervals  return,  in 
order  to  be  invigorated  at  the  head- waters :  he  will  want  to  get  in  touch  with  recent 
improvement,  to  see  in  a  brief  period  a  large  variety  of  interesting  material,  handled 
by  experts  in  his  own  field.  To  both  these  purposes,  the  larger  hospitals  of  our  great 
cities  may  freely  lend  themselves.  Their  abundant  wards  can  be  used  to  excellent 
advantage,  even  though  they  may  continue  to  be  governed  by  their  present  boards. 
It  is  probable  that  the  obstacles  to  such  use  will  largely  disappear  as  the  competitive 
and  commercial  exploitation  of  medical  education  is  itself  abandoned.  For  beyond 
all  doubt,  not  the  least  serious  of  the  deplorable  consequences  that  have  followed  in 
the  wake  of  mercenary  medical  education  is  the  limitation  of  hospital  opportunities, 
due  to  the  rivalry  of  "faculties"  and  to  the  incompetent  student  body  to  which,  largely 
because  of  such  antagonisms,  the  intimacy  of  the  ward  privilege  would  have  had  to 
be  extended. 


1  Our  required  medical  course,  prior  to  practice,  now  covers  four  years.  In  Germany  five  years  must 
be  spent  at  the  university,  a  sixth  in  a  hospital;  in  England,  "official  statistics  published  recently 
under  the  authority  of  the  General  Medical  Council  show  that  the  mean  length  or  the  curriculum  in 
the  case  of  1 1 1 1  students  investigated  was  three  weeks  less  than  seven  years ;  only  14  per  cent  suc- 
ceeded in  obtaining  a  qualification  in  the  minimum  period  of  five  years,  35  per  cent  obtained  it  in  the 
sixth  year,  18  per  cent  in  the  seventh  year,  13  per  cent  in  the  eighth  year.  When  the  remaining  20 
per  cent  obtained  it  does  not  appear,  probably  never.  Looking  at  the  figures  in  another  way,  we 
find  that  at  the  end  of  six  years  less  than  half  had  obtained  a  qualification  for  registration,  and  at 
the  end  of  seven  years  only  two-thirds."  Britith  Medical  Journal,  Sept  5,  1908,  p.  634. 


CHAPTER  VII 

THE  COURSE  OF  STUDY 
THE  HOSPITAL  AND  THE  MEDICAL  SCHOOL 

THE  THIRD  AND  FOURTH  YEARS  (CONTINUED) 

IN  the  end  the  final  test  of  a  medical  school  is  its  outcome  in  the  matter  of  clinicians. 
The  battle  may  indeed  be  lost  before  a  shot  is  fired :  a  low  average  of  student  intel- 
ligence and  inferior  laboratory  training  will  fatally  prejudice  even  excellent  clinical 
opportunities,  for  they  rule  out  certain  essential  features  of  clinical  training  on  a 
modern  basis.  A  serviceable  type  of  doctor  was  doubtless  once  produced  under  con- 
ditions that  we  now  pronounce  highly  unsatisfactory;  again,  students  defectively 
trained  sometimes  meet  with  success  in  examination  or  other  tests  designed  to  ascer- 
tain the  quality  of  their  instruction.  It  is  not  necessary  to  investigate  closely  the 
merits  of  the  test  in  order  to  refute  the  argument  that  it  endeavors  to  sustain.  The 
institutions  that  seek  to  establish  the  non-importance  of  facilities  that  they  do  not 
possess  emphasize  strongly  the  importance  of  those  they  do.  And  with  good  reason. 
Before  undertaking  the  responsibility  of  instruction  in  chemistry  or  physics  or  bio- 
logy, a  competent  teacher  stipulates  that  he  be  provided  with  this,  that,  or  the  other. 
He  is  not  to  be  put  off  with  the  assurance  that  some  men  have  successfully  mastered 
the  subject  without  laboratory  or  tools.  Very  properly  he  takes  the  ground  that 
whatever  may  be  true  of  individuals,  in  general  boys  will  be  much  better  trained  in 
a  laboratory  with  the  essentials  than  in  a  bare  room  practically  without  them.  It  is 
equally  true  of  clinicians.  Doctors  have  after  a  fashion  been  made  by  experience, — 
i.e.,  their  patients  paid  the  price;  further,  some  graduates  of  every  feeble  clinical 
school  in  the  country  have  passed  state  board  examinations  or  obtained  hospital 
appointments,  at  times  after  competitive  examinations  in  which  they  defeated  stu- 
dents from  schools  more  highly  favored;  it  still  remains  true  that  to  do  full  duty  by 
the  young  student  of  clinical  medicine,  his  teachers  need  access  to  acute  cases  of 
disease  in  respectable  number  and  variety;  that  the  school  which  lacks  such  medical 
facilities  is  in  no  position  to  teach  modern  medicine. 

In  the  matter  of  laboratories  we  discovered  no  slight  cause  for  satisfaction.  Within 
two  decades  the  laboratory  movement  has  gained  such  momentum  that  its  future, 
even  its  immediate  future,  is  in  no  doubt.  A  race  of  laboratory  men  has  been  trained 
and  quite  widely  distributed.  They  know  their  place  and  function ;  they  have  edu- 
cated the  college  administrator  to  accept  them  at  their  own  valuation.  Where  deficient 
resources  still  force  a  compromise,  the  apologetic  attitude  is  a  sufficient  promise  of 
more  liberal  provision  by  and  by.  On  the  clinical  side  the  outlook  is  less  reassuring. 
The  profession  itself  has  in  large  measure  still  to  be  educated ;  the  clinical  faculty 
often  stands  between  the  university  administrator  and  a  sound  conception  of  clinical 
training.  It  happens,  therefore,  not  infrequently  that  a  university  president  will  hear 


106  MEDICAL  EDUCATION 

with  astonishment,  if  not  with  resentment,  that  facilities  made  up  of  insecure  and  dis- 
connected privileges  scattered  here  and  there  through  the  hospitals,  public  and  private, 
of  a  community  now  large,  now  small,  do  not  satisfy  the  fundamental  requisites  of 
clinical  discipline  surpervening  upon  modern  laboratory  work;  or  that  a  surgical 
clinic  is  no  substitute  for  a  clinic  in  internal  medicine.  The  regeneration  of  clinical 
education  is  therefore  apt  to  proceed  somewhat  slowly :  the  sources  from  which  well 
trained  clinical  teachers  can  be  drawn  are  few;  the  places  in  which  they  can  be 
freely  utilized  are  equally  restricted.  Students  trained  in  the  laboratories  on  modern 
lines  enter  clinical  departments  still  more  or  less  unconverted.  The  result  is  at  best 
a  half-result,  yet  upon  it  progressive  amelioration  in  large  measure  depends. 

Once  more  a  few  schools  meet  the  specifications  set  forth  in  the  preceding  chapter. 
We  there  urged  that  the  backbone  of  clinical  instruction  must  be  a  pedagogically 
controlled  hospital  best  developed  on  its  medical  side.  The  exact  status  of  the  hospi- 
tal may  indeed  vary :  a  proper  footing  has  been  obtained  now  through  coordinate  and 
cooperative  endowment,1  again  through  state  support  in  connection  with  the  state 
university,3  at  times  through  a  really  effective  affiliation.3  The  crucial  points  are 
these:  (1)  the  hospital  must  be  of  sufficient  size;  (2)  it  must  be  equipped  with  teach- 
ing and  working  quarters  closely  interwoven  in  organization  and  conduct  with  the 
fundamental  laboratories  of  the  medical  school;  (3)  the  school  faculty  must  be  the 
sole  and  entire  hospital  staff,  appointment  to  which  follows  automatically  after  ap- 
pointment to  the  corresponding  school  position ;  (4)  the  teaching  arrangements  to 
be  adopted  must  be  left  to  the  discretion  and  judgment  of  the  teachers,  subject  only 
to  such  oversight  as  will  protect  the  welfare  of  the  individual  patient. 

As  long  ago  as  1869  the  department  of  medicine  of  the  University  of  Michigan 
began  in  a  remodeled  dwelling-house,  capable  of  accommodating  twenty  patients,  the 
development  of  a  university  hospital  on  fundamentally  sound  lines.  From  this  modest 
beginning  a  teaching  hospital  of  two  hundred  beds  has  now  grown  up,  every  patient 
available  for  the  purposes  of  instruction,  in  so  far  as  his  own  welfare  permits.  The 
staff  of  the  hospital  is  the  faculty  of  the  school;  the  ward  service  in  his  own  depart- 
ment is  the  laboratory  of  the  professor.  Ward  rounds  and  amphitheater  clinics  are 
used  for  demonstrative  teaching;  but,  better  still,  students  are  assigned  to  indi- 
vidual cases,  which  they  work  up  at  the  bedside  and  in  the  clinical  laboratory.  An 
isolation  ward  is  provided  for  infectious  diseases;  a  lying-in  ward  is  administered  by 
faculty  obstetricians  and  senior  students;  recently  a  psychopathic  hospital, thoroughly 
modern  in  construction  and  management,  has  been  made  available.  Difficulties,  of 
course,  of  a  serious  nature  have  been  encountered ;  the  state  by  a  liberal  policy  has 
minimized  them.  Ann  Arbor  is  a  small  residential  town;  it  is  necessary  to  attract  or 

1  Johns  Hopkins. 

*  Michigan ;  Iowa. 

*  Lakeside  Hospital   and  Western    Reserve  (Cleveland).  The   newly  endowed   Barnes   Hospital 
(St.  Louis)  will  occupy  \ similar  position  in  reference  to  Washington  University. 


HOSPITAL  AND  MEDICAL  SCHOOL  107 

to  transport  thither  many  cases  from  other  parts  of  the  state.  The  outcome  practically 
formulates  for  us  the  terms  upon  which  such  an  enterprise  is  feasible :  a  modern  equip- 
ment, a  salaried  clinical  faculty,  clean-cut  ideals,  and  careful  husbandry  will  build  up 
a  substantial  clinic  in  a  small  American  as  in  a  small  German  town.  It  can  be  sup- 
plemented by  bringing  the  hospitals  of  the  entire  state  into  working  relation  with 
the  medical  department  of  the  state  university.  The  expense  of  the  establishment  is 
relatively  great;  but  the  advantages  over  a  divided,  perhaps  even  a  remote  depart- 
ment,1 are  on  the  whole  cheap  at  the  price.  How  many  more  such  institutions  we 
should,  however,  now  undertake  to  create  is  of  course  quite  another  question.2 

The  Johns  Hopkins  Medical  School  has  been  even  more  highly  favored.  Its  hos- 
pital endowment  was,  fortunately,  sufficient  to  warrant  a  comprehensive  design  from 
the  start.  The  general  teaching  hospital  then  provided  has  been  recently  supplemented 
by  generous  benefactions  that  add  separate  clinics  for  tuberculosis,  pediatrics,  and 
psychiatry ;  wards,  dispensary,  clinical  and  scientific  laboratories,  cooperate  for  both 
pedagogic  and  philanthropic  purposes.  The  clinical  departments  are  organized  like 
any  other.  Nowhere  else  in  the  country  has  so  consistent  a  scheme  been  so  admirably 
realized.  The  student  is  made  a  factor  in  the  conduct  of  the  hospital :  he  assists  on 
the  clinical  side  as  clerk,  on  the  surgical  side  as  dresser,  following  the  admirable 
method  long  in  vogue  in  the  Scotch  and  English  schools.  In  each  department  he 
serves  an  appointed  novitiate,  following  his  "cases"  from  start  to  finish, — now  to 
recovery,  again  to  autopsy. 

There  is  no  insuperable  reason  why  several  other  medical  schools  should  not  take 
advantage  of  a  fortunate  relation  to  hospitals  to  bring  about  an  equally  effective 
organization.  In  one  place  lack  of  money,  in  another,  hampering  tradition,  alone  pre- 
vents. The  organization  above  described  cannot  be  perfected  unless  these  two  defects 
are  simultaneously  cured.  If  hospitals  are  to  enter  into  exclusive  and  practically  com- 
plete relationship  with  a  single  medical  school,  the  university  must  on  its  side  pro- 
cure funds  which  enable  it  to  be  independent  of  the  local  profession.  Unless  these 
two  conditions  are  coincidently  fulfilled,  the  clinical  situation  cannot  be  thoroughly 
made  over.  Three  Philadelphia  schools  (the  University  of  Pennsylvania,  the  Jeffer- 
son Medical  College,  and  the  Medico-Chirurgical  College),  two  Baltimore  schools 
(the  University  of  Maryland  and  the  College  of  Physicians  and  Surgeons),  and  one 
Chicago  school  (Rush  Medical  College ),s  are  in  sole  and  complete  control  of  excellent 
hospitals,  more  or  less  adequate  in  size.  The  same  intimacy  is  equally  desirable  and 
equally  feasible  for  both  parties  in  interest  between  Wesley  Hospital  and  North- 

1  The  divided  department  is  discussed  from  the  laboratory  side,  page  74 ;  from  the  clinical  side, 
page  119.  For  an  account  of  remote  departments,  see  (Part  II)  University  of  Texas,  University  of 
Indiana,  Cornell  University. 

2  Similar  hospitals,  not  as  yet  so  well  developed,  are  at  present  connected  with  several  other  state 
universities  :  the  Universities  of  Iowa,  Colorado,  Minnesota,  Texas.  The  details  are  given  in  Part  II, 
under  the  several  institutions. 

'But  in  this  instance  the  patient's  consent  must  first  be  obtained. 


108  MEDICAL  EDUCATION 

western  University,1  between  Roosevelt  Hospital  and  Columbia  University.  The  re- 
luctance of  the  hospital  to  go  the  whole  length  is  in  these  latter  cases  the  most  for- 
midable obstacle  to  perfecting  a  relation  that  would  be  of  incalculable  advantage  to 
all  concerned.  For  assuredly  the  university  medical  schools  just  named,  if  offered  com- 
plete teaching  control,  could  cope  with  the  problem  of  procuring  means  with  which 
to  reorganize  their  clinical  faculties  on  a  scientific  and  pedagogical  basis.  The  en- 
lightened action  of  its  trustees  is  rapidly  perfecting  the  same  connection  between  the 
admirable  Lakeside  Hospital  of  Cleveland  and  Western  Reserve  University.  The  new 
Barnes  and  Children's  Hospitals  of  St.  Louis  have  engaged  to  do  as  much  for  the 
reconstructed  medical  department  of  Washington  University.  McGill,  Toronto,  the 
University  of  Manitoba  (Winnipeg),  and  Tulane  are  in  practically  secure  possession 
of  clinical  facilities  that  are  adequate  in  respect  alike  to  extent  and  control.  It  is  to 
be  noted  that  the  schools  above  named  do  not  own  the  hospitals  in  which  their  clini- 
cal teaching  is  given.  Western  Reserve  and  Lakeside  thus  prove  the  feasibility  of  a 
smooth  working  connection  between  a  university  department  of  medicine  and  a  pri- 
vate hospital;  Toronto  proves  the  same  as  between  a  university  medical  school  and 
a  municipal  hospital.  Technically,  neither  set  of  trustees  can  renounce  control;  they 
must  ratify  appointments ;  but  that  act  can  either  be  reduced  to  a  formality  or  ex- 
panded into  meddlesome  supervision,  as  the  trustees  choose.  In  the  two  instances  cited, 
it  has  become  a  mere  form;  and  two  objects,  both  precious,  are  most  effectively  pro- 
moted in  consequence.  On  the  strength  of  these  instances  it  is  perhaps  worth  while 
to  make  one  more  plea  for  an  understanding  between  existing  hospitals  and  deserving 
medical  schools.  Cannot  an  arrangement  be  consummated  by  which  the  administra- 
tion and  financing  of  a  private  or  a  municipal  hospital  shall  be  left  to  the  trustees 
and  their  appointed  agents,  while  equally,  even  though  not  technically,  complete  and 
separate  responsibility  for  the  medical  conduct  of  the  hospital  and  for  teaching 
within  its  wards  is  left  to  the  medical  faculty  ?  As  these  functions  are  absolutely  dis- 
tinct from  each  other,  there  is  no  reason  why  two  bodies  of  intelligent  men,  desirous 
of  doing  right  in  their  respective  spheres,  should  not  thus  cooperate.  If,  of  course, 
the  trustees  are  every  now  and  then  going  to  overrule  the  university  in  the  securing 
of  a  teacher  or  to  overrule  a  physician  in  his  treatment  of  patients,  the  situation  be- 
comes intolerable  and  impossible.  Instances  have  occurred,  for  example,  in  which  the 
board  of  women  managers  of  a  children's  hospital  has  forbidden  the  use  of  lumbar 
puncture.  It  is  not  strange  that  these  things  have  happened,  because  neither  party 
to  the  arrangement  has  had  definite  ideas  as  to  the  limits  of  its  province.  Now,  how- 
ever, that  there  is  no  further  doubt  as  to  just  what  the  trustees  ought  to  do,  on  the 
one  hand,  and  as  to  just  what  the  university  ought  to  do,  on  the  other,  it  would  ap- 
pear an  auspicious  time  for  extending  the  experiment.  The  list  of  teaching  hospitals 
as  above  given  is  so  far  not  large.  It  may,  however,  to  some  extent  be  lengthened  by 

1  At  present,  clinics  at  Wesley  Hospital  are  not  limited  to  Northwestern  University  students. 


HOSPITAL  AND  MEDICAL  SCHOOL  109 

adding  schools  with  hospitals  not  as  yet  adequate  in  size,  of  which  type  the  Univer- 
sity of  Virginia  furnishes  the  most  satisfactory  example.  Long  contentedly  a  didactic 
school,  this  institution  has  just  undertaken  to  develop  a  modern  clinical  department. 
The  new  and  excellent  University  Hospital,  with  eighty  ward  beds,  is  still  under  size. 
But  a  speedy  development  may  be  somewhat  confidently  anticipated.  Its  problem 
is  that  which  Michigan  has  already  shown  how  to  solve;  meanwhile  it  is  perfectly 
clear  that  the  justification  of  such  a  school  lies  in  the  fact  that  its  situation  makes 
possible  the  most  intimate  relations  between  the  clinic  and  the  scientific  laboratories, 
and  a  discipline  in  medical  technique  so  thorough  and  so  vigorous  that  a  few  gaps  in 
the  student's  experience  may  prove  relatively  insignificant.  There  is  every  indication 
that  the  University  of  Virginia  thoroughly  appreciates  both  points. 

By  no  means  every  hospital  owned  by  a  medical  school  is,  however,  to  be  reckoned 
a  teaching  asset.  The  details  require  to  be  closely  scanned.  In  many  cases  they  are 
private  institutions,  in  process  of  being  paid  for  out  of  their  own  profits  and  out  of 
the  fees  of  medical  students,  who  are  lured  by  the  advertisement  of  a  school  hospi- 
tal from  which  they  get  no  good  at  all.  Barnes  Medical  College  (St.  Louis)  adjoins 
Centenary  Hospital,  "  which  affords  clinical  facilities  surpassed  by  none  and  equalled 
by  few;"  but  except  for  part  of  one  floor,  the  building  is  given  over  to  private  rooms.1 

Where  control  ceases,  ideals  necessarily  change.  A  medical  school  with  its  own 
hospital  may  of  course  be  sterile.  Unwise  appointments  may  cut  off  all  possibility 
of  productivity;  too  much  consultant  prosperity  may  be  fatal  to  scientific  zeal;  in- 
breeding may  exhaust  fecundity.  On  the  other  hand,  an  occasional  clinician  may 
keep  his  lamp  trimmed  despite  every  obstacle, — poor  facilities,  a  precarious  term  of 
service,  lack  of  appreciative  sympathy.  Neither  the  one  nor  the  other  contingency, 
however,  militates  against  the  position  that  as  between  the  two  systems  a  school 
hospital  is  in  America  essential  to  the  existence  of  an  efficient  department  of  clinical 
medicine;  that  in  its  absence  the  general  plane  of  instruction  settles  down  to  a  dis- 
tinctly lower  level. 

The  best  of  the  schools  without  a  hospital  which  they  can  call  their  own  do  not 
lack  for  abundance  or  variety  of  clinical  material.  Rush,  Northwestern,  the  College  of 
Physicians  and  Surgeons  (Chicago),  Columbia,  Cornell,  and  the  University  and  Belle- 
vue  Hospital  Medical  College  (New  York),  Harvard  and  Tufts  (Boston),  are  not 
troubled  for  clinical  material;  some  of  them  have  more  of  it  than  they  can  possibly 
use, — much  more  than  several  of  the  university  hospitals  can  ever  hope  to  command. 
But  the  conditions  to  which  they  submit  in  order  to  gain  access  to  it  at  all,  though 
varying  somewhat  from  place  to  place,  are  alike  fatal  to  freedom  and  continuity  of 
pedagogic  policy.  Our  clinical  failure  concurs  with  the  clinical  success  of  the  Germans 
in  proving  that  freedom  is  the  very  life-breath  of  scientific  progress, — freedom  on 

1  Similar  is  the  relation  between  the  medical  department  of  Lincoln  Memorial  University  (Knoxville) 
and  its  hospital  next  door ;  between  the  University  Medical  College  and  the  University  Hospital  (Kan- 
sas City) ;  and  between  the  Milwaukee  Medical  College  and  Trinity  Hospital. 


110  MEDICAL  EDUCATION 

the  part  of  the  university  to  choose  its  own  teachers,  finding  them  where  it  may ; 
freedom  on  the  part  of  the  teachers  to  strike  out  along  whatever  path  they  please. 
An  artificial  impediment  will  in  general  entail  barrenness. 

The  institutions  above  named  are  necessarily  confined  to  the  local  profession  for 
clinical  teachers, — a  restriction  that  they  would  find  intolerable  in  any  other  depart- 
ment and  that  they  endure  under  protest  in  medicine,  only  because  they  are  not  yet 
financially  in  position  to  throw  off  the  yoke.  No  disrespect  to  the  practising  profes- 
sion in  these  large  cities  is  implied:  they  are  doubtless  as  good  doctors  as  can  be 
found  anywhere.  But  they  are  not  teachers;  they  have  neither  time  for,  nor  effective 
interest  in,  productive  teaching.  If  they  were  really  as  much  interested  in  clinical  sci- 
ence as  in  professional  prosperity,  they  could  as  a  body  do  much  to  improve  hospital 
conditions  on  the  pedagogical  side.  As  a  matter  of  fact,  professional  prominence  and 
institutional  rivalry  keep  the  college  tenure  insecure,  often  chop  the  hospital  services 
into  short  terms,  compel  hospital  authorities  to  abridge  teaching  privileges  in  order 
to  avoid  friction,  and  present  a  solid  and  opposing  front  to  the  importation  of  outsid- 
ers, even  though  the  outsider  chance  to  reside  in  the  same  town.  Under  such  condi- 
tions it  becomes  at  once  impossible  to  entertain  in  clinical  medicine  the  ideals  set  up 
in  the  laboratories  of  pathology,  physiology,  or  chemistry.  One  pitches  one's  ex- 
pectations lower.  It  becomes  a  scramble  for  abundance  and  variety  of  "facilities'*  on 
the  part  of  the  schools ;  public  hospitals  split  up  and  overload  their  services  in  order 
to  distribute  their  favors  widely;  private  institutions  promote  their  prosperity  by  de- 
clining exclusive  alliances.  In  Chicago  staff  positions  in  the  great  Cook  County  Hos- 
pital are  awarded  every  six  years  by  competitive  examination;  and  the  schools  make 
what  terms  they  can  with  the  winners,  who  rotate  from  ward  to  ward  at  stated  pe- 
riods. No  bedside  clinics  are  allowed;  patients  are  wheeled  into  teaching-rooms  or 
amphitheaters  for  demonstration ;  anyone  who  purchases  a  ticket  may  attend  any 
clinic  that  he  pleases.  The  student  gets  an  excellent  chance  to  see  detached  conditions; 
what  he  loses  is  the  opportunity  to  observe  individual  cases  of  disease  in  process  of 
development  and  to  correlate  his  own  laboratory  findings  with  symptoms  observed 
at  the  bedside.  As  for  the  professors,  whisked  about  in  rotation,  scientific  study  is 
out  of  the  question.  At  Bellevue  Hospital  (New  York),  Columbia,  Cornell,  and  New 
York  University  have  each  a  "division,"  within  which,  however,  they  are  not  supreme; 
the  medical  board,  composed  of  the  entire  visiting  staff  of  all  three  schools  and  the 
fourth  division, — the  outsiders, — limits  the  freedom  of  the  several  parties  in  interest; 
final  authority  is  lodged  with  a  lay  board,  who  have,  for  example,  recently  overruled 
Columbia  in  its  own  division.  At  Boston  neither  Harvard  nor  Tufts  has  the  initia- 
tive in  filling  staff  positions  in  the  hospitals  used  in  teaching.  Appointments  are 
made  by  seniority;  it  is  well-nigh  impossible  for  the  school  to  break  the  line.  In 
Boston  as  in  New  York,  the  large  hospitals  tend  to  have  their  own  pathological  de- 
partments, the  permanence  of  whose  relation  to  the  corresponding  department  of 
the  medical  schools  is  decidedly  uncertain.  Money  and  educational  opportunity  are 


HOSPITAL  AND  MEDICAL  SCHOOL  111 

thus  both  wasted.  As  a  rule,  services  rotate  every  three  or  four  months;  the  hospitals 
sometimes  provide  clinical  laboratory  space  in  which  students  work.1  All  these  in- 
stitutions possess  supplementary  facilities.  In  general,  however,  supplementary  clini- 
cal opportunities  are  of  fragmentary  and  precarious  character;  the  medical  school 
has  as  such  no  uniform  constitution,  nor  is  a  single  department  an  organized  entity; 
clinical  clerks  may  be  employed  by  one  teacher  for  three  months,  only  to  be  spurned 
by  his  successor  in  the  service  at  the  close  of  his  brief  term.  Fresh  pathological  ma- 
terial may  be  procured  by  giving  a  faculty  appointment  to  a  coroner's  physician, 
while  the  professor  of  pathology  scours  the  city  in  vain  for  admission  to  a  dead -room; 
instead  of  compact  departments  pulling  as  a  whole  towards  a  definite  goal,  a  half- 
dozen  professors  of  medicine  and  surgery  stand  on  an  equal  footing,  each  compelled 
to  conform  to  conditions  imposed  by  the  hospital  on  the  staff  of  which  he  is  a  tran- 
sient sojourner,  or  holding  the  whip-handle  over  his  own  school,  because  the  school 
cannot  antagonize  the  clinical  professor  without  imperiling  its  clinical  opportuni- 
ties correspondingly.  The  normal  relation  of  school  and  teacher  is  inverted.  The 
question  is  not,  "Who  is  a  good  teacher?"  but  rather,  "Who  controls  a  hospital 
service?"  In  a  large  city,  the  curtain  rises  on  a  dozen  hospitals,  each  already  provided 
with  a  staff,  and  several  medical  schools,  each  requiring  a  faculty  of  men  who  can 
bring  as  their  dower  "clinical  facilities."  There  is  a  lively  competition:  at  once,  every 
holder  of  a  hospital  service  finds  himself  a  potential  professor  of  medicine,  surgery,  or 
whatnot.  When  the  scramble  is  over,  the  counted  spoils  appear  in  the  catalogue  in 
the  form  of  a  list  of  the  hospitals  "open  to  students  of  this  school."  The  hospital 
appointments  are  therefore  valuable  "plums."  They  give  the  holders  the  call  in  the 
matter  of  school  rank;  and  school  positions  are  still  in  most  places  of  substantial 
commercial  value.  It  happens,  in  consequence,  that  the  schools  under  discussion  are 
put  together  of  two  dissimilar  pieces :  the  laboratory  branches  are  of  one  texture, 
the  clinical  branches  of  another.  The  laboratory  men  are  imported;  their  produc- 
tivity has  been  increased  by  crossing  the  breed.  The  clinical  men  are  local2  and,  with 
some  notable  exceptions,  contentedly  non-productive.  There  is  little  intercourse  across 
the  line  in  either  direction.  The  redeeming  feature  of  these  schools  is,  then,  simply 
the  amount  and  variety  of  clinical  material  that  their  students  see. 

The  plane  drops  once  more  as  we  leave  behind  these  large  schools  and  approach 
the  next  class.  Conditions  now  become  rapidly  worse  through  aggravation.  Hospital 
management  becomes  increasingly  unsympathetic  or  unintelligent,  thus  keeping  the 
schools  on  the  anxious  bench.  In  truth,  not  much  can  be  expected.  "Amongst  the 

1  In  a  few  services  a  continuous  term  prevails  for  the  time  being,  — sometimes  by  arrangement  among 
the  teachers  themselves,  sometimes  by  way  of  personal  compliment  to  an  individual.  Welcome  as 
such  improvements  are,  they  are  far  from  curing  the  trouble. 

2  One  can  in  a  few  lines  give  a  complete  list  of  schools  that  can  and  do  go  outside  the  local  profession 
to  procure  clinical  teachers  :  Johns  Hopkins,  University  of  Michigan,  University  of  Virginia,  Yale, 
Tulane  (in  medicine),  University  of  Pennsylvania,  and  Washington  University.  These  institutions 
have  imported  perhaps  a  score  or  two  of  clinical  teachers ;  there  are  almost  4000  more  clinical  pro- 
fessors in  the  United  States  and  Canada  who  are  practising  local  doctors. 


112  MEDICAL  EDUCATION 

hospital  superintendents  I  know  of,  there  are,  besides  a  very  few  physicians,  an  ex- 
newspaper  reporter,  a  ward  boss,  a  china  factory  hand,  various  clerks,  and  a  still 
more  varied  assortment  of  clergymen.  ...  In  order  that  domestic  complaints  may 
be  removed,  a  committee  of  ladies  is  sometimes  appointed,  .  .  .  their  only  claim  to 
knowledge  being  that  of  the  'born  housekeeper'  supposed  to  be  inherent  in  every 
woman.  The  organization  and  management  of  institution  households,  however,  hav- 
ing little  in  common  with  that  of  a  few  maids  and  no  sick  people,  the  management 
of  details  by  visiting  committees  is  often  but  an  added  discomfort."1 

Such  institutions  are  mere  boarding-houses  for  the  sick.  Physicians  call  there  as 
they  call  at  a  private  house,  seeing  twenty  patients  in  the  former  instance,  a  single 
patient  in  the  latter.  It  is  the  difference  between  wholesale  and  retail, — no  other; 
scientifically  the  "  calls "  are  on  the  same  level.  The  visiting  staff  of  physicians  is  ap- 
pointed through  favor,  pull,  or  bargain,  and  the  schools  make  the  best  of  it.  A  small 
clique  occasionally  controls  the  situation.  Conspicuous  fitness  cannot  be  the  sole  or 
main  consideration.  A  school  rich  in  facilities  to-day  may  be  beggarly  to-morrow. 
The  medical  department  of  Toledo  University  has  just  lost  its  main  clinical  sup- 
port as  one  outcome  of  a  local  political  overturning.  The  University  of  Minnesota 
has  been  fortunately  hastened  in  the  resolution  to  build  its  own  hospital  because  a 
local  upset  reduced  its  former  privileges.  The  Woman's  Medical  College  of  Phila- 
delphia adjoins  a  hospital  of  which  its  faculty  was  once  the  staff;  now  there  is  no 
commerce  between  them.  The  Hering  Medical  College  at  Chicago  (homeopathic)  is 
in  even  closer  proximity  to  a  homeopathic  hospital :  a  bridge  connects  them ;  but  the 
barred  doorway  bears  the  legend,  "  No  students  admitted."  Medical  politics  are  de- 
cisive at  Albany ;  to  keep  control  in  the  hands  of  the  dominant  clique  of  the  Albany 
Medical  School  (the  medical  department  of  Union  University),  the  size  of  the  fac- 
ulty was  recently  increased,  all  the  new  members  being  adherents  of  the  side  in 
power.  The  City  Hospital  at  St.  Louis,  the  County  Hospital  at  Denver,  are  frankly 
described  as  being  "in  politics."2  Staff  appointments  made  for  personal  or  political 
reasons  may  of  course  be  revoked  for  reasons  that  are  no  better.  The  uncertainty  of 
any  one  connection  constitutes  a  good  reason  for  getting  hold  of  as  many  as  possible. 
Columbia,  for  example,  used  to  be  supreme  at  Roosevelt  Hospital,  opposite  its  lab- 
oratories; it  is  being  gradually  edged  out, — a  deplorable  condition  for  all  concerned; 
but  it  has  recompensed  itself  abundantly  elsewhere.  The  medical  department  of  the 
George  Washington  University  protects  itself  by  providing  that  "every  clinical 
teacher  shall  cease  to  be  such  teacher  should  his  facilities  for  giving  clinical  instruc- 
tion cease  before  the  end  of  his  term  of  service."8  If  a  school  drops  an  indifferent 
teacher,  it  may  be  worse  off  than  if  it  retained  him ;  for  he  keeps,  and  the  school 
loses,  the  "clinical  facilities'"  that  he  represents.  St.  Louis  University,  in  purchasing 

1  Banfielcl,  loc.  fit.,  pp.  42,  43  (abridged).  Occasionally,  feeling  is  cordial,  as  at  Topeka,  for  example. 

'The  same  is  admitted  at  Halifax,  N.  S. 

8  Ordinance  to  Reorganize  the  Department  of  Medicine,  section  3. 


HOSPITAL  AND  MEDICAL  SCHOOL  118 

its  present  medical  department,  contracted  to  keep  the  clinical  professors  in  their 
chairs  for  a  term  of  years.  When  the  term  expires,  they  are  free  to  drop  them, — at 
the  cost,  however,  of  cutting  down  their  clinics  in  the  same  ratio.  In  a  few  places 
things  are  held  together  somewhat  more  compactly  by  an  arrangement  that  gives 
the  school  faculty  the  hospital  services  during  term  time.  Such  is  the  case  at  Mobile, 
Birmingham,  and  Chattanooga.  But  in  general  a  hospital  staff  is  composed  of  hetero- 
geneous elements,  appointed  for  reasons  that  cannot  be  classified.  Representatives  of 
no  school  and  representatives  of  all  schools,  serving  now  through  the  year,  again  for 
a  few  weeks,  now  in  one  ward  only,  now  rotated  through  several,  make  up  a  situa- 
tion unfavorable  to  every  interest  involved.  In  New  York  the  ancient  ecclesiastical 
evil  of  plural  benefices  crops  out  unexpectedly :  one  individual  may  hold  several  ap- 
pointments in  hospitals  so  far  removed  from  each  other  that  he  cannot  possibly  do 
even  his  perfunctory  duty  by  them ;  instead  of  surrendering  superfluous  perquisites, 
he  sub-lets  them  at  will,  according  as  fancy  or  personal  interest  may  determine :  the 
staff  appointments  appended  to  his  name  are  so  many  scalps  hung  about  his  belt ! 
There  is  no  such  thing  as  hospital  policy :  the  wards  have  as  little  wholeness,  as  little 
intimacy  of  relation  with  each  other,  as  the  private  homes  in  which  these  same  physi- 
cians treat  their  personal  patients;  only  a  local  accident  puts  one  roof  over  them. 

Teaching  is  obviously  but  an  incident  in  the  routine  of  these  institutions.  Not 
infrequently  amphitheaters  have  been  included  in  their  construction ;  but  they  usu- 
ally lack  a  clinical  laboratory  in  which  students  may  work,  not  a  few  lack  it  altogether. 
The  failure  to  provide  clinical  laboratory  space  thus  keeps  instruction  to  the  level  of 
passive  demonstration.  The  student  has  presumably  spent  two  years  in  mastering  cer- 
tain medical  sciences.  A  large  part  of  this  laboratory  discipline  was  designed  to  en- 
able him  to  gather  a  greater  variety  of  facts  than  the  bedside  examination  will  dis- 
close. Blood,  sputum,  urine,  etc.,  all  contain  important  evidence  which  the  laboratory 
years  equip  the  student  to  utilize.  He  has  been  taught  to  do  certain  things.  But  at 
the  critical  moment,  when  doing  them  will  count,  he  may  get  no  chance,  in  the  first 
place,  because  at  many  hospitals,  among  them  those  mainly  relied  on  by  the  Univer- 
sity of  Nebraska  (Omaha),  Denver  and  Gross  (Denver),  the  Hahnemann  Medical  Col- 
lege (Philadelphia),  and  most  southern  schools,  there  is  no  clinical  laboratory  at  all. 
At  Denver  "there  is  no  equipment  to  make  a  culture,  and  the  internes  are  rarely 
equal  to  it,  anyway.""  At  Omaha,  the  clinical  microscopist  of  the  university  faculty 
was  unable  even  to  get  material  from  the  County  Hospital;  when  he  wanted  gastric 
juice  for  demonstration,  he  had  to  manufacture  it  himself.  In  the  second  place,  where 
a  clinical  laboratory  is  provided,  "students"  are  as  a  rule  not  admitted.  The  work 
is  done  by  a  resident  pathologist  who  has  no  connection  with  any  of  the  several 
"schools'"  that  are  permitted  to  demonstrate  cases  in  the  amphitheater  or  in  the 
wards;  or  by  internes,  equally  detached  and  too  frequently  of  very  doubtful  com- 
petency by  reason  of  just  the  educational  limitations  we  are  deploring.  To  the  clinical 
laboratories  connected  with  the  municipal  hospitals  of  St.  Louis,  Chicago,  Minne- 


114  MEDICAL  EDUCATION 

apolis,  students  have  no  access,  though  in  these  hospitals,  rich  in  material,  the  students 
of  St.  Louis  University,  Rush  and  the  College  of  Physicians  and  Surgeons  (Chicago), 
the  University  of  Minnesota,  respectively,  ought  to  be  getting  the  best  part  of  their 
clinical  training.  Not  infrequently  it  is  alleged  that  the  students  do  "carry  material 
for  examination  back  to  the  college:"  the  students  of  the  Creighton  School  (Omaha) 
and  of  the  Los  Angeles  schools  would  thus  have  to  transfer  specimens  of  urine,  feces, 
and  gastric  contents  on  the  street  cars  across  town, — distances  of  several  miles.  At 
Southwestern  University  (Dallas,  Texas),  a  section  of  four  students  has  an  assigned 
patient  at  the  City  Hospital,  perhaps  a  mile  and  a  half  distant,  where  there  is  no 
clinical  laboratory  ;  to  work  up  material,  they  must  carry  it  to  the  college  building, 
— where  there  is  no  clinical  laboratory,  either.  Educationally,  an  "academic"  labo- 
ratory discipline  that  thus  hangs  loose,  that  cannot  be  brought  to  bear  on  specific 
clinical  cases,  must  be  largely  wasted.  There  is  no  merit  in  making  a  blood-count 
unless  the  student  has  been  disciplined  to  connect  the  blood-count  with  all  other 
symptoms  of  the  patient  whose  blood  is  counted.  As  it  is,  he  beholds  a  patient,  sees 
things  pointed  out,  may  even  listen  to  his  heart-beat ;  away  off  in  the  college  labo- 
ratory, he  has  previously  examined  some  one's  urine,  counted  some  one's  blood,  tested, 
perhaps,  an  artificially  prepared  gastric  juice.  But  there  is  no  connection;  the  dis- 
cipline splits  in  the  middle.  Scientific  habits  of  practice  are  not  established  in  that 
way.  Nor  are  loose  habits,  thus  contracted,  cured  by  an  interneship.  Pupils  are  more 
apt  to  disappoint  than  to  astonish  their  teachers;  they  do  not  generally  better  their 
instruction.  In  consequence  hospital  records  made  by  internes  graduated  by  these 
schools  are  scant  and  unsystematic.  Defective  methods  at  the  University  of  Buffalo 
were  extenuated  on  the  plea  that  as  internes  they  learn  better ;  but  the  meager  records 
of  the  Buffalo  General  Hospital  disprove  the  claim.  Whoever  is  responsible,  poorly 
kept  records  are  very  apt  to  denote  inferior  bedside  instruction.  The  situation  is  this : 
there  lies  the  patient ;  teacher,  interne,  and  students  surround  the  bed.  The  case  is  up 
for  discussion.  A  question  arises  that  requires  for  its  settlement  now  a  detail  of  the 
patient's  previous  history,  now  a  point  covered  by  the  original  physical  examination, 
now  something  brought  out  by  microscopic  examination  at  some  time  in  the  course 
of  the  disease.  If  complete,  accurate,  and  systematic  records  hang  at  the  bedside,  there 
is  an  inducement  to  ask  questions ;  doubtful  matters  can  be  cleared  up  as  fast  as  they 
are  suggested.  That,  then,  is  the  place  for  the  records, — full  records,  at  that.  In  few 
instances  are  the  records  full ;  in  still  fewer  are  they,  full  or  meager,  in  easy  reach. 
At  the  University  of  Kansas,  at  Lane  Hospital  (Cooper  Medical  College,  San  Fran- 
cisco), there  is  no  uniform  method  of  making  or  keeping  records :  "  some  men  do 
better  than  others;"  "it  depends  on  the  man."  At  the  Protestant  Hospital,  Colum- 
bus, Starling-Ohio  graduates  are  internes,  the  records  are  nurses'  charts ;  at  Trinity 
Hospital  (Milwaukee),  attached  to  the  Milwaukee  Medical  College,  the  same  is  true.1 

1  Similar  instances  can  be  cited  from  all  other  sections  of  the  country  :  the  records  are  nurses'  charts 
at  the  hospital  of  the  College  of  Physicians  and  Surgeons,  Little  Rock,  and  at  the  City  Hospital  — 


HOSPITAL  AND  MEDICAL  SCHOOL  115 

The  clinical  facilities  of  the  ordinary  medical  school  are  put  together  of  scraps,  the 
general  character  of  which  have  now  been  described.  They  offer  a  medical  clinic  here, 
an  obstetrical  clinic  there,  a  skin  clinic  somewhere  else.  Faculties  numerically  out  of 
all  proportion  to  the  number  of  students  are  assembled  in  order  to  piece  out  the 
quilt :  Fordham  University  has  72  instructors  for  42  students;  the  New  York  Medi- 
cal College  for  Women  has  45  instructors  for  24  students;  the  Toledo  Medical  Col- 
lege, 48  instructors  for  32  students ;  the  Oakland  College  of  Medicine  and  Surgery, 
42  instructors  for  17  students.  As  the  hospitals  are  scattered,  time  is  wasted  in  going 
to  and  fro.  All  told,  our  150  medical  schools  have  resulted,  among  other  things,  in 
some  4000  professorial  titles.1 

Imagine  the  engineers  that  would  be  produced  if  students  were  sent  to  a  series  of 
shops  to  see  things  done, — as  far  as  they  could  be  seen  without  interfering  with  the 
workmen !  In  no  two  of  these  hospitals  is  exactly  the  same  kind  of  teaching  privi- 
lege granted;  and  the  privileges  granted  are  highly  precarious:  the  hours  are  arbi- 
trarily limited,  and  number  of  beds  is  usually  too  small.  Nowhere  do  they  approach 
the  ideal  which  the  school  might  readily  institute  in  its  own  hospital.  They  fall 
short,  however,  in  varying  degrees.  In  St.  Louis  the  situation  is  lamentable.  The 
City  Hospital  has  a  medical  and  surgical  staff  who  "do  no  teaching,"  and  a  teaching 
staff  who  "do  no  doctoring."  Fjach  of  the  half-dozen  schools  in  the  town  has  one 
afternoon;  the  instructor  must  go  out  to  the  hospital  the  day  before  to  select  two 
cases  for  demonstration, — an  amount  of  trouble  which  the  better  men  are  reluctant 
to  take.  The  instruction  consists  in  pointing  out  features  and  suggesting  what  ought 
to  be  done :  in  surgery,  it  may  have  been  done  already ;  in  medicine,  there  is  no  tell- 
ing. In  either  case,  the  entire  process  remains  purely  hypothetical.  These  opportu- 
nities are  not  infrequently  treated  as  they  deserve:  at  the  St.  Louis  College  of  Physi- 
cians and  Surgeons  it  was  stated:  "This  is  hospital  day;  lots  of  them  don't  go."  In 
the  County  Hospital  at  Los  Angeles,  the  main  reliance  of  two  university  depart- 
ments of  clinical  medicine, — one  of  them  (the  University  of  California)  requiring  for 
admission  three  years  of  college  work, — students  are  not  permitted  to  handle  sur- 

used  by  two  schools — at  Memphis  ;  at  Ensworth  Hospital,  one  line  in  a  ledger  contains  all  the  facts 
on  record ;  at  Topeka,  the  same  is  true  ;  it  is  added  that  "  laboratory  reports  are  not  kept,  and  physi- 
cal examinations  could  not  be  found ;"  the  histories,  made  up  by  internes  at  the  Kansas  City  Hos- 
pital, are  so  irregular  that  "  the  visiting  staff  don't  even  read  them."  They  are  imperfect  at  the  Uni- 
versity of  Texas  (Galveston) ;  defective  and  careless  at  the  Maine  General  Hospital  (Portland). 
1  See  Table  in  Appendix,  for  a  complete  list.  The  disproportion  in  point  of  number  between  laboratory 
and  clinical  chairs  is  instructive.  For  example  : 

NUMBER  or  FCLL  PROFESSORS  IN 


Institution          Anatomy 
Cornell                                 2 
Columbia                             1 
St.  Louis                              1 
Denver  and  Gross               1 
University  of  Louisville     1 

Pathology 
2 
2 

1 
1 
1 

Physiology 
1 

1 
8 
1 
1 

Medicine 
3 
8 
5 
5 
4 

Surgery  (not  in- 
cluding gynecology) 
9 
5 
6 
5 
8 

Contrast  with  these 
Johns  Hopkins 


116  MEDICAL  EDUCATION 

gical  patients,  and  teachers  "shall  not  conduct  bedside  clinics  when  possible  to  re- 
move patients  from  the  ward;"1  on  these  terms  100  beds  are  available,  for  six  hours 
weekly  in  surgery,  and  perhaps  for  a  few  more  in  medicine.  At  Creighton,  students 
"witness  the  operation,"  and  are  admitted  to  about  90  beds.  In  Denver,  students 
"are  not  much  at  the  bedside;  they  just  look  on;"  the  hours  are  from  8.30  to 
10  a.m.,  daily, — the  early  hour  having  been  fixed,  it  is  alleged,  to  prevent  the  atten- 
dance of  the  state  university  boys  at  Boulder.  There  are  "ward  classes"  at  Memphis — 
as  many  as  fifty  students  in  a  group  at  once ! 

Where  things  are  patched  up  in  the  way  described,  it  is  of  course  impossible  that 
proportions  and  relations  should  be  observed.  We  have  urged  that  the  backbone  of 
clinical  training  must  be  internal  medicine.  But  it  is  precisely  here  that  the  schools 
are  in  general  weakest.  The  sum  total  of  accessible  beds  may  amount  to  a  hundred : 
not  infrequently  less  than  one-fifth  of  them  will  contain  medical  cases.  The  "addi- 
tional facilities "  of  the  larger  schools  are  mainly  surgical  in  character;  and  in  gen- 
eral, the  less  a  school  has  to  offer  in  the  way  of  clinical  facilities,  the  more  heavily 
is  surgery  overweighted.  Its  pedagogical  value  is  relatively  slight;  for  operations  are 
performed  in  large  amphitheaters  in  which  the  surgeon  and  his  assistants  surround 
the  patient,  to  whom  they  give  their  whole  mind,  in  practical  disregard  of  the 
students,  who  loll  in  their  seats  without  an  inkling  of  what  is  happening  below.  Most 
of  the  students  see  only  the  patient's  feet  and  the  surgeon's  head.  Only  in  rare  cases, 
previously  mentioned,  in  which  the  student  helps  to  form  the  machine,  do  desig- 
nated individuals  take  turns  and  become  part  of  the  operation, — making  the  exam- 
ination, watching  the  procedure  at  close  range,  and  "cleaning  up"  afterwards. 
Inadequacy  in  general  is  thus  aggravated  by  increasing  predominance  of  surgical 
over  medical  clinics.  Clinical  teaching  thus  tends  more  and  more  to  concentrate 
in  the  amphitheater.  The  laboratory  side  sinks  further  and  further  into  the  back- 
ground; the  bedside  work  becomes  more  and  more  contracted.  The  whole  thing  is 
demonstrative — and  at  steadily  increasing  remoteness.  At  the  University  of  Ver- 
mont juniors  and  seniors  have  most  of  their  medical  and  surgical  clinics  together, 
averaging  in  medicine  about  three  hours  weekly  one  year  and  four  hours  weekly  the 
next ;  and  the  work  is  mostly  in  the  amphitheater.  Dartmouth  Medical  School  has 
access  to  24  beds,  eighty  per  cent  of  the  patients  occupying  which  are  surgical  cases. 
Bowdoin — to  complete  the  list  of  the  smaller  New  England  schools — uses  the 
Maine  General  Hospital,  Portland,  where  surgery  greatly  predominates.  Tufts  has  an 
imposing  array  of  clinical  facilities;  but  its  medical  clinic  is  limited  to  the  Boston  Dis- 
pensary and  one  service  in  the  City  Hospital.  Kansas  Medical  College  relies  almost 
wholly  on  three  hospitals,  in  which  it  gets  a  total  of  nine  or  ten  hours^  instruction 
weekly  :  in  two  of  the  three  hospitals  all  the  work  is  surgery;  in  the  remaining,  two- 
thirds  of  it.  In  the  university  hospital  at  Rosedale  (University  of  Kansas),  there  were 
last  year  240  patients,  190  of  them  surgical;  six  free  beds  are  this  year  reserved  for 

1  Rulet  and  Regulations,  Lot  Angela  County  Hospital,  section  4,  rule  12. 


HOSPITAL  AND  MEDICAL  SCHOOL  117 

medicine.  Of  course,  the  school  has  privileges  elsewhere;  but  this  small  hospital  is 
all  that  it  controls,  though  two  years  of  college  work  are  required  for  admission. 
The  Starling-Ohio  Medical  College  (Columbus)  uses  several  hospitals:  in  one  150 
beds  are  open,  "mostly  surgical;"  in  another  40  beds,  "mostly  surgery."  The  De- 
troit College  of  Medicine  has  access  to  two  hospitals;  one  of  them,  with  100  teach- 
ing beds,  is  fortunate  in  a  fairly  equal  division  between  medicine  and  surgery;  the 
other  describes  its  work  as  nine-tenths  surgical.  The  clinical  instruction  of  Ep- 
worth  University  (Oklahoma  City)  is  given  in  a  hospital  within  which  30  to  40 
beds  are  available,  two-thirds  to  three-quarters  of  the  cases  being  surgical.  Drake  Uni- 
versity uses  30  beds  during  a  weekly  total  of  twelve  or  fifteen  hours  in  two  hospitals, 
in  neither  of  which  is  the  student  essentially  other  than  a  passive  witness.  The  Chicago 
College  of  Medicine  and  Surgery — being  the  medical  department  of  Valparaiso 
University — has  a  hospital  of  75  beds,  about  one- fourth  usable  for  teaching;  the 
Bennett  Medical  College  (Chicago)  has  a  hospital  of  40  beds,  20  claimed  as  free;  at 
Chattanooga,  the  city  hospital  contained,  all  told,  in  the  course  of  the  year  1908 
something  over  500  patients;  at  Augusta,about  300.  Temple  University  (Philadelphia) 
has  a  hospital  with  20  free  beds;  the  Woman's  Medical  College  (Philadelphia),  27; 
the  New  York  Eclectic  Medical  College  sends  parties  limited  to  three  students  to  the 
Sydenham  hospital  twice  weekly.  The  Physio-Medical  College  of  Chicago  got  along 
last  year  with  167  patients;  Western  University  (London,  Ontario)  has  access  to  an 
average  of  less  than  30  beds  a  year.  At  Trinity  Hospital  (Milwaukee),  with  75  beds, 
mostly  pay,  —  a  part  of  Milwaukee  Medical  College, — nine-tenths  of  the  cases  or 
more  are  surgical. 

We  have,  however,  by  no  means  even  yet  exhausted  the  subject  of  arbitrary  clinical 
limitations.  As  a  rule,  only  the  general  medical  and  surgical  wards  are  open  at  all. 
Few  of  the  hospitals  possess  an  isolating  ward,  and  not  all  of  these  permit  students 
to  see  infectious  diseases.  The  instruction  in  that  important  branch  is  therefore 
usually  didactic.  This  holds  true  of  some  schools  that  ask  two  years  of  college  work  for 
entrance,  Yale  and  the  University  of  Kansas  among  them.  It  is  true,  too,  of  the  New 
York  Medical  College  for  Women,  the  University  Medical  College  (Kansas  City), 
the  Starling-Ohio  (Columbus),  the  University  of  Tennessee,  Baylor  University  and 
Southwestern  University  (Dallas),  Louisville,  Little  Rock,  Memphis,  etc.  At  Albany 
it  was  stated  that  the  hospital  has  a  pavilion  for  infectious  diseases,  which  the  school 
might  use :  "  it  does  n't,  because  the  students  are  afraid."  But  the  very  worst  showing 
is  made  in  the  matter  of  obstetrics.  Didactic  lectures  are  utterly  worthless.  The 
manikin  is  of  value  only  to  a  limited  degree.  For  the  rest,  the  student  requires  dis- 
cipline and  experience.  The  safety  and  comfort  of  both  patients — mother  and  child — 
depend  on  the  trained  care  and  dexterity  of  the  physician.  The  practice  is  a  fine  art 
which  cannot  be  picked  up  in  the  exigencies  of  out-patient  work,  poorly  supervised 
at  that.  Principles,  methods,  technique,  can  be  learned  and  skill  acquired  only  in 
an  adequately  equipped  maternity  hospital ;  only  after  that  is  the  student  fit  to  be 


118  MEDICAL  EDUCATION 

trusted  with  the  responsibilities  of  the  out-patient  department.  Difficulties  and  limi- 
tations in  such  matters  sit  lightly  on  most  of  our  medical  schools.  The  hospitals  of 
Atlanta  and  Los  Angeles  exclude  students  from  the  obstetrical  ward;  at  Burling- 
ton there  is  no  obstetrical  ward,  but  the  "students  see  more  or  less;"  at  Denver  a 
"small  amount"  of  material  is  claimed;  at  Birmingham  it  is  "very  scarce;"  at  Chat- 
tanooga there  are  "  about  ten  cases  a  year,"  to  which  students  are  "  summoned,"  how 
or  by  whom  is  far  from  clear.  At  the  Hahnemann  Medical  College  (Chicago)  stu- 
dents "look  on  at  internes  who  do  the  work;"  a  committee  of  the  Missouri  state 
board  reports  of  the  College  of  Physicians  and  Surgeons  of  St.  Louis  that  it  could 
find  only  incomplete  records  of  21  cases  for  a  senior  class  of  57 ;  at  Augusta,  Georgia, 
the  cases  "  always  come  at  night  when  you  can't  get  students;"  at  Charlotte  15  cases 
were  available  from  September  15  to  February  4;  the  medical  department  of  Lincoln 
Memorial  University  (Knoxville)  has  no  out-patient  department,  but  alleges  "a  few 
deliveries  before  the  class;"  Vanderbilt  relies  on  out-patient  work  mostly.  There  is  a 
senior  class  of  almost  150  at  the  American  School  of  Osteopathy  (Kirksville,  Mis- 
souri). In  two  months  they  had  eight  clinical  cases  in  obstetrics.  Perhaps  most 
lamentable  of  all,  the  Woman's  Medical  College  of  Baltimore  concedes  its  opportu- 
nities to  be  "inadequate."  At  Toledo,  Louisville,  the  University  of  Tennessee,  Kan- 
sas City,  the  University  of  Kansas,  Albany,  and  Yale,  obstetrics  is  practically  alto- 
gether out-patient  work ;  that  is  to  say,  the  student  gets  about  the  same  training  as 
a  mid- wife.  At  Willamette  (Salem,  Oregon)  he  probably  does  not  get  even  that:  for 
"obstetrics  depends  on  private  practice  and  is  very  precarious.  The  student  sees  a 
delivery  when  the  doctor  is  willing  to  take  him." 

Not  a  few  of  the  schools  mentioned  have  elevated  their  entrance  requirements 
until  they  already  demand  one  or  two  years  of  college  work  for  entrance,  or  expect 
to  do  so  presently.1  Meanwhile  their  clinical  facilities  remain  what  they  were. 
Doubtless  some  of  them  will  make  haste  to  improve, — Yale,  for  example.  Others 
will  probably  recede  from  their  announced  elevation, — as  several  have  already  done. 
Assuredly,  students  who  improve  their  preparation  will  demand  that  the  schools 
improve  their  facilities  correspondingly.  In  the  laboratory  years  this  has  generally 
taken  place :  he  will  be  a  dull  fellow  who  does  not  quickly  feel  and  resent  the  inferi- 
ority of  the  clinical  end.  In  all  fairness,  the  betterment  of  the  facilities,  the  change 
of  spirit  and  ideal,  ought  to  have  preceded  as  the  warrant  for  the  higher  entrance 
standard.  For  the  two-year  college  standard  proclaims  a  university  department.  It 
still  remains  to  be  demonstrated  that  towns  like  Omaha,  Washington,  San  Francisco, 
Toj>eka,  Milwaukee,  can  recruit  university  faculties  from  the  local  profession.  A  univer- 
sity connection  or  a  two-year  college  entrance  requirement  do  not,  of  themselves,  trans- 
form a  medical  school  faculty.  They  merely  impose  upon  it  an  additional  strain. 

The  strain  to  which  high  entrance  standards  and  good  laboratory  teaching  at 

1  Kansas  Medical  College,  Dartmouth,  Yale,  Creighton,  Denver  and  Gross,  Hahnemann  (Chicago), 
Starling-Ohio,  Milwaukee  Medical,  Wisconsin  College  of  Physicians  and  Surgeons,  etc. 


HOSPITAL  AND  MEDICAL  SCHOOL  119 

once  subject  the  clinical  end  is  distinctly  apparent  in  the  remote  half  of  the  divided 
school.  We  have  already1  considered  the  perplexities  of  the  laboratory  end  without 
contact  with  clinics.  They  appeared  not  insoluble.  Whether  two  clinical  years  given 
by  themselves  with  practising  physicians  as  teachers  can  ever  form  a  substan- 
tial texture  is  highly  problematical.  The  latter  half  of  a  divided  school  is  given  by 
the  University  of  California  at  San  Francisco,2  by  the  University  of  Nebraska  at 
Omaha,3  by  the  University  of  Kansas  in  a  suburb  of  Kansas  City,*  by  Bowdoin  Col- 
lege at  Portland.5  The  American  Medical  Missionary  College  carries  division  still 
further.  It  is  divided  between  Battle  Creek  and  Chicago;  but  no  single  year  is  en- 
tirely given  in  either  place.  Every  class  is  shifted  in  the  course  of  the  year  from  one 
town  to  the  other.  Nor  does  the  division  end  here;  for  at  Chicago,  the  clinical  in- 
struction is  divided  so  that  different  pieces  are  given  at  widely  separated  places.  These 
pieces  do  not  touch  each  other,  and  none  of  them  ever  touches  the  laboratory  work 
given  in  Battle  Creek.  Indeed,  none  of  the  detached  clinical  departments  is  doing  well. 
The  vitality  of  the  clinic  depends  on  the  closeness  of  its  commerce  with  the  laboratory 
branches;  otherwise  the  clinical  end  is  not  rooted.  Thus  far  none  of  these  has  achieved 
either  executive  or  scientific  intimacy.  A  certain  degree  of  executive  unity  may  per- 
haps be  secured  through  a  dean  freely  circulating  between  the  two  parts,  though  if 
he  is  attached  as  professor  to  one  end  of  the  department,  the  other  is  apt  to  resent 
intrusion.  Scientific  unity  seems  in  any  case  unattainable.  The  clinical  men  at  Omaha 
or  San  Francisco  simply  cannot  be  at  home  in  the  laboratories  of  Lincoln  or  Berkeley. 
Laboratories  must  be  duplicated  at  the  clinical  site  if  the  clinicians  are  to  be  in  touch 
with  them :  in  which  case  the  divided  type  of  school  tends  to  turn  into  the  whole  re- 
mote type  illustrated  by  the  medical  departments  of  the  universities  of  Texas  at 
Galveston,  Indiana  at  Indianapolis,  and  of  Cornell  at  New  York.  The  truth  is  that  an 
efficient  medical  school  is  a  compact  whole,  in  which  geographic  unity  of  labora- 
tories and  hospital  is  essential  to  scientific  and  educational  integrity.  The  wilted 
condition  of  the  clinical  ends  of  the  divided  schools  is  a  warning  that  Michigan, 
now  contemplating  the  removal  to  Detroit  of  the  final  year  in  medicine,  may  well 
weigh.  Even  separation  of  the  two  parts  within  one  city  is  a  disadvantage.6  Division 
seems  justifiable  only  as  a  temporary  expedient  to  get  clinical  material,  pending  a 
choice  between  concentration  of  the  entire  school  at  one  point  or  the  other,  or  out- 
right abandonment  of  clinical  instruction  in  favor  of  a  two-year  school.7 

1  Page  74. 

2  First  half  given  at  Berkeley.  The  latter  half  will  be  duplicated  at  Los  Angeles.  Leland  Stanford 
Junior  will  shortly  give  the  latter  half  of  its  medical  course  at  San  Francisco,  too ;  its  first  half  is 
given  at  Palo  Alto. 

3  First  half  given  at  Lincoln. 

4  First  half  given  at  Lawrence. 
8  First  half  given  at  Brunswick. 

6  As  at  Rush  (University  of  Chicago). 

7  Several  of  the  southern  state  universities  and  the  University  of  Colorado  are  in  this  position. 


120  MEDICAL  EDUCATION 

Meanwhile  we  are  not  without  schools  that  have  practically  no  hospital  connec- 
tion at  all.  The  Mississippi  Medical  College  (Meridian)  has  absolutely  no  hospital 
facilities  or  privileges  of  any  sort  whatsoever.  The  Georgia  College  of  Eclectic  Medi- 
cine and  Surgery  (Atlanta),  the  California  Eclectic  Medical  College  (Los  Angeles), 
are  in  the  same  plight.  Others  are  hardly  better:  for  example,  the  three  Chicago 
night  schools,  one  of  which,  the  National  Medical  University,  had  two  lonely  pa- 
tients on  the  top  floor  of  the  school-building,  though  claiming  the  usual  relations 
with  a  private  pay  institution.  Thrice  happy  for  the  nonce  is  the  Hippocratean  Col- 
lege of  Medicine  (St.  Louis),  a  night  school;  it  crosses  no  clinical  bridges  till  it  reaches 
them :  as  it  is  only  three  years  old,  it  need  not  bother  about  hospital  connections  until 
next  year!  The  Lincoln  (Nebraska)  Medical  College  deplores  the  fact  that  "there  are 
no  poor  in  Lincoln ;  hence  students  have  no  regular  hours  at  any  hospital,  but  de- 
pend on  cases  as  they  turn  up."  The  Hahnemann  Medical  College  of  Chicago  has  two 
surgeons  on  the  Cook  County  Hospital  staff  and  a  hospital  of  60  beds;  but  the  lay 
superintendent  "does  n't  believe  in  admitting  students  to  the  wards,  so  that  there  is 
no  regular  way  for  them  to  see  common  acute  diseases."  The  College  of  Physicians  and 
Surgeons,  Denver,  had  access  to  a  hospital  of  28  beds,  "certain  ones  free."  The  medi- 
cal school  at  Little  Rock  that  trades  on  the  name  of  the  University  of  Arkansas, 
with  which  it  is  not  even  affiliated,  is  connected  by  a  bridge  with  a  city  hospital 
that  has  a  capacity  of  from  twenty-five  to  thirty-five  patients,  some  of  whom  are  oc- 
casionally transported  across  into  the  amphitheater  for  operation  or  exhibition.  The 
clinics  of  the  medical  department  of  Willamette  University  (Salem,  Oregon)  are  some- 
what intangible:  whether  medical  clinics  are  held,  and  where,  "depends  on  the  cases." 
Not  infrequently,  schools  advertise  varied  hospital  connections  that  prove  on  inves- 
tigation to  be  baseless  or  surreptitious.  The  Philadelphia  College  of  Osteopathy  claims 
"the  freedom  of  every  important  surgical  clinic  in  the  great  medical  colleges  and  hos- 
pitals** of  that  city.  Its  hospital  list  is  almost  a  page  long;  at  the  top  stand  the  Uni- 
versity and  Jefferson  Hospitals,  to  which  its  students  can  gain  access  only  by  conceal- 
ing their  identity.  Rights  or  privileges  they  have  none.  The  College  of  Physicians  and 
Surgeons  of  Boston  announces  that  "equal  opportunities  and  privileges  are  available 
in  the  hospitals  and  institutions"  of  that  city, — a  flagrant  misstatement;  for  the  stu- 
dents of  that  institution  can  on  payment  of  fee  attend  only  certain  public  clinics  of 
little  value. 

It  is  unnecessary  to  describe  dispensary  conditions  in  equal  detail:  naturally  they 
parallel  the  hospital  situation.  The  same  clinicians  are  responsible  for  both;  in  general, 
the  dispensaries  would  be  likely,  therefore,  to  reflect  the  samedegree  of  intelligence  and 
conscientiousness.  A  teaching  dispensary  needs  ample  space,  equipment  for  making  the 
necessary  diagnostic  examinations  and  for  taking  simple  therapeutic  or  surgical  mea- 
sures on  the  spot,  a  well  organized  staff,  and  a  thorough  record  system,  in  the  keep- 
ing of  which  students  serve  as  clerks.  Voluminous  attendance  is  an  advantage,  because 
it  permits  selection  in  the  first  place,  repeated  illustration  of  important  conditions  in 


HOSPITAL  AND  MEDICAL  SCHOOL  121 

the  second.  It  may  be  set  down  as  fundamental  that  a  good  dispensary  will  not  run 
itself;  that  nothing  in  the  way  of  equipment  will  be  used  that  is  not  actually  there. 
Economy  of  time  is  of  such  importance  to  both  teachers  and  students  that  makeshift 
inevitably  means  neglect.  The  well  conducted  dispensaries  are  the  well  equipped  and 
well  organized  dispensaries.  The  moment  that  equipment  and  organization  fail,  omis- 
sion begins;  no  general  rule  prescribes  where  it  will  stop. 

Vanderbilt  Clinic — the  dispensary  attached  to  the  College  of  Physicians  and  Sur- 
geons,New  York  (Columbia University) — represents  in  respect  to  facilities  the  school 
dispensary  at  its  best.  Teaching  and  treatment  rooms,  ample  in  size  and  equipment 
from  the  standpoints  of  both  students  and  patients,  are  provided;  a  clinical  labora- 
tory, with  working  space  for  every  student  on  duty,  is  part  of  the  building;  close 
correlation  of  physical  examination  and  laboratory  tests  is  feasible.  An  admirably 
kept  card  index  facilitates  the  keeping  and  use  of  data;  there  was  an  attendance  in 
1908  of  almost  50,000  patients,  making  over  160,000  visits.  The  Johns  Hopkins  Dis- 
pensary and  the  Lakeside  Dispensary,  operated  by  Western  Reserve,  are  equally  ef- 
ficient. Less  sumptuously  housed,  but  adequate  in  all  essential  respects,  are  the  dis- 
pensaries of  Cornell,  New  York  University,  the  three  Philadelphia  schools,  and  those 
open  in  Boston  to  Harvard  and  Tufts.  The  Polhemus  Clinic  controlled  by  the  Long 
Island  College  Hospital,  the  Homeopathic  Medical  Dispensary  controlled  by  the 
Boston  University  School  of  Medicine,  must  be  included  in  the  number  of  excel- 
lently housed,  equipped,  and  organized  institutions  of  this  kind.1  Yale  has  an  excellent 
building,  which  the  application  of  a  few  thousand  dollars  yearly  will  readily  convert 
into  an  effective  teaching  adjunct.2 

The  first  break  comes  in  the  care  with  which  an  abundant  attendance  is  handled. 
It  would  seem  probable  that,  where  the  records  are  careless  and  incomplete,  the 
treatment  of  patients  is  likely  to  be  hurried.  The  compilation  and  arrangement  of 
data  slow  the  pace.  They  conduce  to,  and  usually  indicate,  thoroughness  and  de- 
liberation,—  of  fundamental  importance  if  the  student  is  to  acquire  a  cautious  habit. 
Lack  of  system  and  superficiality  tend  to  run  together.  Mere  mass  of  material,  swiftly 
handled,  may  be  useful  to  experienced  practitioners  in  affording  a  variety  of  cases 
among  which  occasionally  something  rare  and  interesting  may  turn  up;  but  a  stu- 
dent who  is  in  such  a  dispensary  initiated  into  the  routine  of  practice  will  be  fortu- 
nate ever  to  form  methodical  and  thorough  working  habits.  The  Los  Angeles  clinical 
branch  of  the  University  of  California  possesses  a  thoroughly  admirable  dispensary 
building.  Some  of  the  rooms  are  well,  some  ill  equipped ;  the  records  are  brief  and 
non-significant;  no  report  is  compiled;  and  the  clinical  laboratory,  indispensable  to 
intelligent  conduct  of  an  out-patient  department  concerned  to  mould  the  student's 

1 A  few  institutions  possess  small,  moderately  well  equipped  dispensaries,  the  conduct  of  which  in- 
dicates conscientious  desire  to  do  the  best  possible  under  the  circumstances.  Creditable  examples  are 
the  dispensary  of  Drake  University  (Des  Moines)  and  the  South  End  Dispensary  used  by  the  Albany 
Medical  School. 

2  Denver  and  Gross  also  has  an  excellent  dispensary  building. 


122  MEDICAL  EDUCATION 

habits  and  to  do  well  by  its  patients,  is  both  defective  and  disorderly:  the  surgical  in- 
strument case  contained  a  tack-hammer,  candle-ends,  and  other  equally  incongruous 
miscellaneous  objects  among  its  instruments.  In  the  medical  department  of  the  Uni- 
versity of  Cincinnati,  there  is  a  card  index  alphabetically  arranged ;  but  the  results 
of  the  physical  examination  are  not  given,  nor  is  there  any  note  of  the  treatment 
advised.  The  Starling-Ohio  Medical  College  (Columbus)  has  a  clean  dispensary,  with 
adequate  attendance,  but  no  records  in  a  proper  sense  at  all;  Halifax  Medical  Col- 
lege requires  attendance  at  a  city  dispensary  that  possesses  little  equipment  for  treat- 
ment, still  less  for  teaching;  besides,  the  college  has  no  voice  in  its  conduct.  The 
students  of  Syracuse  University  also  attend  a  city  dispensary,  but  the  head  clinical 
professors  know  nothing  about  what  they  get,  or  fail  to  get,  there.  Utterly  destruc- 
tive of  good  habits  of  observation  or  treatment  must  be  a  dispensary  like  the  North 
End  Dispensary,  Kansas  City,  attended  by  the  students  of  the  state  university; 
equipment  and  records  are  alike  defective  and  confused.  But  there  are  others  much 
worse.  Dispensary  suites  are  found  at  the  Barnes  Medical  College  and  the  College  of 
Physicians  and  Surgeons  (St.  Louis).  The  former  claims  an  annual  attendance  of 
10,000  cases.  Several  rooms  are  provided,  those  devoted  to  branches  like  gynecology 
and  surgery  being  especially  filthy.  The  equipment  for  internal  medicine  consists  of 
a  small  dirty  room  and  a  few  miscellaneous  bottles  of  proprietary  drugs  scattered  on 
the  shelves  of  a  bookcase.  The  dispensary  of  the  College  of  Physicians  and  Surgeons 
is  of  the  same  general  character:  the  gynecological  room,  for  example,  is  without  a 
window,  water,  or  instruments;  all  is  dark  and  dingy;  there  are  no  records  of  cases; 
evasive  answers  are  made  to  all  questions.  The  fact  is  that  a  dispensary,  costing  little 
to  keep  and  nothing  to  run  beyond  the  expense  of  a  drug  room,  cannot  answer  for 
teaching.  Nor  can  youthful  volunteers  be  usually  relied  on  to  form  an  efficient  staff. 
The  expenditure  on  the  score  of  dispensary  must  be  greatly  increased  if  the  material 
that  presents  itself  is  to  be  effectively  handled  in  the  training  of  students. 

These  schools  shade  off  imperceptibly  into  those  that  make  no  pretense  to  a  dis- 
pensary at  all,  passing  on  the  way  institutions  like  Birmingham  Medical  College, 
with  a  department  both  small  and  poor ;  Augusta,  without  case  records,  not  even 
prescriptions  put  up  in  the  pharmacy  being  numbered ;  Portland  (Oregon),  claiming 
two  to  seven  a  day;  the  Jenner  (Chicago),  claiming  two  to  ten  nightly;  the  Physio- 
Medical  (Chicago),  with  perhaps  250  all  of  last  year;  the  Eclectic  (New  York),  using 
"  what  comes  to  the  college ;"  Charlotte,  with  loose  unnumbered  cards,  mostly  unin- 
telligible, the  prescription  files  showing  an  average  of  four  or  five  a  day.  At  the  De- 
troit Homeopathic  College  one  finds  prescriptions  written  on  scraps  of  paper,  envelope 
backs,  etc.,  with  neither  numbers  nor  names ;  at  the  Cleveland  Homeopathic  Medical 
College  "  medical  cards  are  kept  in  pigeonholes  that  are  cleaned  out  every  spring." 
The  Kansas  City  Eclectic  school  is  hopeful,  if  not  ambitious  :  its  dispensary  atten- 
dance averages  now  "  about  three  daily ; "  they  hope  to  be  able  "  to  work  it  up  to 
six."  The  medical  department  of  Bowdoin  College  uses  a  dispensary  at  Portland  that 


123 

has  an  attendance  of  eight  or  ten  a  day  :  there  are  no  case  records,  not  even  a  pre- 
scription file,  no  clinical  laboratory,  and  not  so  much  as  a  microscope  on  the  premises. 
The  University  of  Alabama  (Mobile)  is  the  only  small  southern  school  with  decent  dis- 
pensary quarters:  an  attractive  wing  has  been  recently  built  for  the  purpose  by  the 
state. 

There  remains  still  the  goodly  number  of  schools  that  possess  absolutely  no  dis- 
pensary provision  at  all.  With  some  of  them  we  are  already  familiar  as  destitute  of 
hospital  facilities.  Without  dispensary  teaching  of  any  kind,  their  students  enter  the 
homes  of  the  poor, — to  officiate  at  childbirth,  to  care  for  wage- workers  on  whose  well- 
being  depends  the  independence  of  the  family.  Meridian,  the  Georgia  Eclectic,  Wil- 
lamette, the  Lincoln  Eclectic,  the  Hospital  Medical  College  (Atlanta),  the  American 
Medical  College1  (St.  Louis),  the  Chattanooga  Medical  College,  Western  University 
(London,  Ontario),  are  representative  schools  of  this  description.  It  is  painful  to  in- 
clude in  essentially  the  same  class  the  Medical  College  of  the  State  of  South  Caro- 
lina, at  Charleston,  which  in  lieu  of  a  school  dispensary  refers  to  the  out-patient  work 
of  the  Roper  Hospital,  with  which  its  students  have  nothing  at  all  to  do.  The  two 
Dallas  schools — both  long  without  a  dispensary — are  now  starting  one;  Ensworth 
Medical  College  at  St.  Joseph,  Missouri, — a  city  of  130,000, — has  practically  no  dis- 
pensary at  all;  Epworth  University  (Oklahoma  City)  is  in  the  same  plight.  Not  a  few 
of  these  institutions  might  develop  a  fair  dispensary  service  if  their  opportunities  were 
intelligently  cultivated.  For  example,  the  University  of  Buffalo,  in  a  city  of  400,000, 
has  a  wretched  dispensary  with  a  daily  attendance  of  from  twelve  to  fifteen,  if  one 
can  judge  by  sampling ;  for  tabulated  records  there  are  none.  Such  notes  as  exist  are 
brief  and  irregular.  The  poor  do  better  to  suffer  in  silence  rather  than  to  trust  to  the 
haphazard  student  medication  that  such  institutions  now  supply. 

Astonishing  to  relate,  the  conditions  that  have  been  portrayed  are  defended.  It  is 
alleged  in  extenuation  that  "our  graduates  pass  state  board  examinations,  get  hos- 
pital appointments,  succeed  in  practice.""  It  is  quite  true:  what  of  it?  The  argument 
if  valid  would  commit  every  school  above  the  lowest  to  deliberate  deterioration  of 
its  facilities.  Bowdoin  makes  light  of  a  wretched  dispensary  on  the  grounds  above 
cited ;  Dartmouth  men  succeed  by  the  same  tests  without  any  dispensary  at  all ;  ergo, 
Bowdoin  may  safely  forego  dispensary  teaching  altogether.  Is  it  not  obvious  that 
both  are  mistaken?  that  they  take  hold  of  the  situation  at  the  wrong  end?  Medical 
education  is  nowadays  a  definite  problem,  the  factors  to  which,  the  end  of  which, 
may  be  specifically  stated.  We  know  exactly  what  it  drives  at;  we  can  determine  to 
a  nicety  the  means  necessary  to  reach  the  goal  thus  set  up.  It  will  shortly  be  demon- 
strated that  the  number  of  doctors  needed  can  in  most  sections  be  supplied  with- 
out material  departure  from  the  conditions  agreed  on.  Why,  then,  should  they  be 
abandoned  ?  In  order  that  local  doctors  may  continue  to  develop  their  professional 

1  At  this  school  one  is  naively  told  that  they  have  "a  dispensary  room,  and  almost  every  day  some 
one  comes." 


124  MEDICAL  EDUCATION 

business?  In  order  that  "historic"  schools  may  continue  to  produce  a  slightly  amel- 
iorated type  of  didactically  trained  physician? 

As  a  matter  of  fact,  many  of  the  schools  mentioned  in  the  course  of  this  recital 
are  probably  without  redeeming  features  of  any  kind.  Their  general  squalor  consorts 
well  with  their  clinical  poverty:  the  class-rooms  are  bare,  save  for  chairs,  a  desk,  and 
an  occasional  blackboard;  the  windows  streaked  with  dust  and  soot.  In  wretched 
amphitheaters  students  wait  in  vain  for  "professors,"  tardy  or  absent,  amusing  the 
interval  with  ribald  jest  and  song.  The  teaching  is  an  uninstructive  rehearsal  of  text- 
book or  quiz-compend :  one  encounters  surgery  taught  without  patient,  instrument, 
model,  or  drawing;  recitations  in  obstetrics  without  a  manikin  in  sight, — often 
without  one  in  the  building.  Third  and  fourth  year  men  are  frequently  huddled  to- 
gether in  the  same  classes.  At  the  Memphis  Hospital  Medical  College  the  students 
of  all  four  years  attend  the  same  classes  in  many  of  the  subjects  taught. 

So  much  for  the  worst.  It  may  be,  however,  that  in  the  case  of  some  schools  with 
weak  hospitals  and  no  dispensaries,  the  didactic  instruction  is  vigorous,  clean  cut,  in 
its  way  effective.  Such  is  the  claim  made  at  Dartmouth  and  at  Bowdoin.  Let  us  con- 
cede its  justice:  what  of  it?  Logically,  the  position  of  these  institutions  would  be 
stronger  if  they  stuck  to  didactic  instruction  altogether.  The  moment  that  they 
offer  a  course  in  clinical  microscopy,  they  are  committed  to  an  entirely  different  scale 
of  values.  For  that  they  require  patients  whom  they  can  observe  closely  and  contin- 
uously in  order  that  laboratory  data  and  bedside  data  may  be  put  together  as  the 
basis  of  a  specific  judgment.  In  other  words,  teaching  must  henceforth  be  concrete, 
not  abstract;  clinical,  not  didactic.  Good  didactic  instruction  may  indeed  to  some 
extent  accompany  clinical  teaching.  We  are  not  especially  concerned  to  determine  its 
actual  extent.1  Let  it  earn  the  school  an  extra  credit,  if  you  please.  But  its  excellence 
is  no  substitute  for  missing,  defective,  or  badly  balanced  clinical  opportunities. 


1  The  subjoined  comparative  schedule  indicates  the  distribution  between  clinical  and  didactic  work  in 
schools  of  various  grades.  This  table  is  not  alone  conclusive ;  for  schools  with  weak  clinical  resources 
are  not  infrequently  without  illustrative  material,  so  that  a  clinical  lecture  may  perforce  turn  into  a 
didactic  lecture.  Moreover,  clinical  instruction  of  the  amphitheater  type  may,  if  the  students  are 
few  and  the  conditions  good,  be  as  useful  as  a  bedside  demonstration ;  where,  however,  the  students 
are  many  and  the  conditions  poor,  it  may  be  no  better  than  a  didactic  exposition. 


COMPARATIVE  SCHEDULE,  THIRD  AND  FOURTH  YEARS 

THIRD  YEAR 


WESTERN  RESERVE  UNIVERSITY 


NEW  YORK  UNIVERSITY 


MEDICO-CIURUROICAL  COLLEGE  UNIVERSITY  or  ALABAMA 


Subject 

Hours 

Subject 

Hours 

Subject 

Hours 

Subject 

Hours 

Inatomy 

Did. 

Lab. 

Clin. 

Pathology 

Did. 

Lab. 

Clin. 

Anatomy 

Did. 

Lab. 

Clin. 

Anatomy 

Did. 

Lab. 

Chn. 

Applied  anatomy 

96 

Demonstrations 

64 

Applied  anatomy 

48 

Anatomy  of  the 

*athology   and  Preven- 
tive Medicine 

Applied  patholo- 
gy 

32 

64 

Path.  <t  Bacteriology 
Pathology 

96 

eye,  ear,  nose, 
and  throat 

14 

Gross  pathological  ana- 

Bacteriology 

64 

Bacteriology 

32 

Pathology 

tomy 
Autopsy  technique 
Hygiene    and    preven- 
tive medicine 
yharmacology,   Materia 
Medico.  <6  Therapeutics 
Pharmacology 
Therapeutics 
Advanced  prescription 
writing 
fedicine 
Physical  diagnosis 
Medicine  and  clinical 
medicine 
Clinical  microscopy 

40 

84 
32 

64 
35 

32 
10 

20 
6 

105 

68 
96 

Pharmacology 
Lectures 
Therapeutics 
Lectures  and  re- 
citations 
Medicine 
Lectures  and  re- 
citations 
Section  work  :  "J 
hospital,  ills-  1 
pensary,  and  f 
bedside          J 
Clinics 
Diseases  of  chil- 
dren 

16 
96 
192 

64 

96 
96 

Surgical  pathology 
Autopsies 
Therapeutics 
Lectures  and  recita- 
tions 
Therapeutic  clinics 
Prescription  dis- 
pensing 
Medicine 
Med.  &  clinical  med. 
Pathological    physi- 
cal diagnosis 
Children's  diseases 
Nervous  and  mental 
diseases 

32 
128 

64 

32 
32 

i 

16 
64 

32 

64 
i 
32 

32 

Lectures,    reci- 
tations,    and 
laboratory 
Therapeutics 
Lectures     and 
recitations 
Electro  -  thera- 
peutics1 
Medicine 
Lectures     and 
clinics1 
Physical    diag- 
nosis 
Clinical     diag- 
nosis 

28 
56 

56 
28 

112 
56 

56 

112 

Medical  dispensary 
forgery 
History  taking 
Surgical  diagnosis 
Fractures  and  disloca- 
tions 
Genito-urinary  surgery 

12 

20 

18 
12 

24 

Surgery 
Lectures  and  re- 
citations 
Section  work  :  ^ 
hospital,  dis-  1 
pensary,  and  f 
bedside          J 

192 

96 
96 

History  taking 
Surgery 
Lectures  and  recita- 
tions 
Clinics 
Operative  surgery  & 
bandaging 

192 

i 
50 

128 

Surgery 
Lectures     and 
clinics1 
Obstetrics 
Lectures      and 
recitations1 

38 
112 

112 

Principles  of  surgery 
Clinical  surgery 
Surgical  pathology 

64 

60 

64 

Olinics 
Operative  sur- 
gery 

Dhatfifri  fa 

32 

Orthopaedic  surgery 

Obstetrics  and  Oyne- 
cology 

32 

Surgery  dispensary 
Eye,  ear,  nose,  &  throat 

32 

36 
24 

\jusiei  'iics 
Lectures  and  re- 
citations 

96 

Obstetrics 
Gynecology 

96 
32 

i 
32 

Obstetrics  db  Gynecology 

Manikin  work 

8 

Specialties 

Obstetrics 

64 

Lying-in  hospital 

3 
wks. 

Ophthalmology 

32 

Gynecology 

32 

12 

Oynecology 

Laryngology 

16 

Recitations    and 

Otology 

16 

demonstrations 

32 

Dermatology 

32 

1  On  clou  ichedule 

Medical  Jurispru- 
dence dk  Toxicology  ' 

32 

at  "  Eltctrieity." 
'  Ciinict     are     the 

tame  for  3d    and 

1  Section     work  ;     exact 

ith  year  clauet. 

numberofhoun  not  given. 

3  Clatt    tchedule 

1  Part  of  thit  teork  it  lab- 

slwtct only  one  reci- 

oratory. 

tation  per  week. 

FOURTH  YEAR 


WESTERN  RESERVE  UNIVERSITY 

NEW  YORK  UNIVERSITY 

MKDICO-CHIRUROICAL  COLLEGE 

UNIVERSITY  or  ALABAMA 

Subject 

Hours 

Subject 

Hours 

Subject 

Hours 

Subject 

Hours 

^athology  &  Preventive  Med. 

Did. 

Clin. 

Pathology 

Did. 

Clin. 

Pathology 

Did. 

Clin. 

Medicine 

Did. 

C/m. 

Hygiene 

24 

Conference 

32 

Autopsies 

i 

Medical  clinics1 

112 

Preventive  medicine 

20 

Pathologic  chemistry 

6 

Therapeutics 

Nervous  and  mental 

Medical  jurisprudence 

20 

Autopsies 

8 

Applied  therapeutics 

i 

diseases 

42 

fedicine 

Therapeutics 

Medicine 

Tropical  medicine 

56 

Medicine  and  clinical  med. 
Physical  diagnosis 

96 

96 
50 

Conferences 
Hygiene 

32 
32 

Theory  and  practice 
Clinical  medicine 

192 

96 

State  medicine 
Dispensary,  all  sub- 

•    _j_  ] 

28 

Ward  clinics 
Bedside  work 

40 
32 

Special  subjects 
Medicine 

30 

Medical  dispensary 
Diseases  of  children 

i 
88 

jecis 
Dermatology 

28 

28 

Dispensary  medicine 
Clinical  microscopy 

i 

50 

Recitations  &  clinics 
Section  work 

60 

96 
72 

Pediatrics  dispensary 
Nervous  and  mental  dis- 

i 

Surgery 
Lectures  and  recita 
lions 

TO 

Diseases  of  children 

32 

50 

Neurology 

32 

12 

eases 

16 

48 

Plini/*a  * 

4  \f 

Diseases  of  nervous  system 
Dermatology  and  syphilis 
Medical  ethics,  economics, 

32 
64 

23 
27 

Diseases  of  children 
Mental  diseases 
Dermatology 

48 
16 
32 

20 
16 

Dermatology 
Dispensary  dermatology 
Surgery 

16 

32 

a 

v^  11I11C9 

Operative  surgery 
Genito-urinary  sur- 
gery 

112 
84 

OS 

and  Roentgenology 

1 

Surgery 

Lectures  and  recitations 

192 

Hospital  section 

•v 

Surgery 

Recitations  &  clinics 

92 

96 

Clinics 

work1 

70 

Surgical  diagnosis 

12 

Section  work 

72 

Genito-urinary  surgery 

16 

Obstetrics   and   Oyn- 

Recitations 

20 

Genito-urinary    sur- 

Orthopaedic surgery 

ecology 

Clinical  surgery 

192 

gery 

32 

24 

Ophthalmology 

Obstetrics  lectures 

56 

Dispensary  surgery 

50 

Orthopaedic  surgery 

32 

4 

Laryngology 

Gynecology  lectures 

56 

Ward  work,  clinical  mi-"| 
croscopy,    and    assign-  - 
ment  to  cases                  J 
Ophthalmology 
Eye  dispensary 
Ear,  nose,  and  throat 
Obstetrics  and  Gynecology 
Obste  tries 

32 
64 

64 

50 
50 

i 

Obstetrics  and  Gfyneco- 
logy 
Obstetrics 
Gynecology 
Specialties 
Ophthalmology 
Otology 

34 

32 

16 

52 

16 
16 

Otology 
Obstetrics  and  Oynecology 
Obstetrics 
Clinical  obstetrics  and' 
manikin  work             f 
Gynecology 
Gynecology  ward  clinics 

64 
64 

i 

32 

> 

Other  Subjects 
Hygiene  and  medi- 
cal jurisprudence 
Ear  &  nose  diseases 
Eye  and  throat  dis- 
eases 
Ophthalmology 

28 
56 

84 

28 

i 

Laryngology 

16 

20 

Clinical  gynecology 

64 

1  Whfn  material  it  available. 

1  Clinics  open  to  3d  £  ith 
year  clattet. 

Dispensary  gynecology 

50 

1  Section    work;    number  of 

-'  Ciinict  only  for  iih  year 

Number  of  hours  varies. 

hours  not  given. 

clatt. 

CHAPTER  VIII 
THE  FINANCIAL  ASPECTS  OF  MEDICAL  EDUCATION 

AN  examination  of  the  financial  aspects  of  the  American  medical  school  will  com- 
pletely account  for  the  conditions  that  have  been  described.1  It  is  universally  con- 
ceded that  medical  education  cannot  be  conducted  on  proper  lines  at  a  profit, — 
or  even  at  cost;  but  it  does  not  follow  that  it  has  therefore  ceased  to  "pay."  It  is 
commonly  represented  that  medical  schools  are  benevolent  enterprises,  to  which  self- 
ish financial  considerations  are  nowadays  quite  alien.  Such  is  not  even  generally  the 
case.  Our  best  medical  schools  are  indeed  far  from  self-supporting ;  they  absorb  the 
income  of  large  endowments  or  burden  seriously  the  general  resources  of  their  respec- 
tive universities.  But  these  institutions  constitute  but  a  small  fraction  of  the  medi- 
cal schools  of  the  country.  The  others  pay  in  one  or  more  of  several  ways,  if  "  pay- 
ing" is  understood  to  mean  that  the  fees  do  more  than  meet  the  expense  of  running 
the  school.  This  use  of  terms  is  entirely  justifiable;  for  if  fees  alone  are  inadequate 
to  meet  the  running  expenses  of  an  up-to-date  medical  school,  then  the  difference 
between  actual  expenditure  on  instruction,  with  its  essential  incidentals,  and  the 
total  fee  income  of  the  school  is  profit,  whatever  the  use  to  which  it  is  applied.  In 
the  worst  cases  this  sum  is  great  and  goes  into  the  pockets  of  the  teachers ;  in  many 
others,  it  may  not  be  large  in  any  single  year,  though  its  total  over  a  stretch  of 
years  may  be  quite  sufficient  to  have  altered  materially  the  complexion  of  the  in- 
stitution. In  these  schools  an  annual  balance  to  the  good  is  obtained  for  distribu- 
tion by  slighting  general  equipment,  by  overworking  laboratory  teachers,  by  wholly 
omitting  certain  branches,  by  leaving  certain  departments  relatively  undeveloped, 
or  by  resisting  any  decided  elevation  of  standards.  In  one  or  more  of  these  ways,  for 
example,  not  to  go  outside  the  Empire  State,  the  Albany  Medical  School  is  enabled 
to  pay  some  $500  a  year  apiece  to  otherwise  well-to-do  clinicians;  the  University  of 
Buffalo  to  distribute  "nominal  sums"  of  $1000  to  a  number  of  professors  in  large 
regular  practice ;  the  Long  Island  College  Hospital  to  apportion  a  substantial  sum 
out  of  the  fee  income  in  tithes  among  the  faculty;  and  the  University  and  Bellevue 
Hospital  Medical  College  to  pay  out  of  fees  salaries  to  some  of  the  most  successful 
practitioners  in  New  York  city,  while  the  laboratory  branches  still  lack  anything 
like  uniform  development.  More  favorable,  but  still  by  no  means  beyond  the  reach 
of  legitimate  criticism,  is  the  case  of  schools  that,  admitting  the  impossibility  of 
providing  satisfactory  instruction  at  cost,  nevertheless  save  from  current  use  a  not 
inconsiderable  amount  to  be  applied  to  paying  for  buildings  or  plant  instead  of 
dividends.  Every  such  saving  is  necessarily  at  the  expense  of  instruction ;  that  is 
to  say,  if  every  dollar  taken  in  were  consumed  in  current  teaching,  unfortunate  make- 
shifts would  still  have  to  be  employed.  With  every  dollar  less  than  total  fee  income 
1See  appendix  for  table  showing  income  of  medical  schools. 


FINANCIAL  ASPECTS  127 

used  in  providing  teaching,  the  quality  of  instruction  is  still  further  impaired.  As 
the  country  becomes  able  and  willing  to  support  at  a  loss  the  number  of  schools 
needed,  the  ethical  justification  of  other  schools  that  must  pay  a  profit — even  though 
that  profit  go  into  buildings  and  equipment — becomes  decidedly  dubious. 

Most  of  the  existing  medical  school  plants  have  been  provided  in  this  manner ; 
quite  commonly  those  who  have  participated  in  the  operation  fail  to  reflect  on  its 
significance.  For  if  a  good  medical  education  costs  more  than  the  student  pays  in 
fees,  then,  even  though  an  adequate  plant  has  been  provided  in  advance,  his  instruc- 
tion must  at  some  essential  points  be  curtailed  if  additional  income  is  not  availa- 
ble. If,  however,  fees  must  provide  either  initial  plant  or  plant  extension,  it  is  clear 
that  proper  teaching  must  be  still  further  refused  during  the  years  when  fees  are 
employed  to  accumulate  equipment.  Historically  that  is  the  explanation  of  our 
extensive  medical  school  plants  in  New  York,  Philadelphia,  Baltimore,  Louisville, 
Chicago:  instruction  far  below  what  was  at  the  moment  scientifically  feasible  was 
given  to  the  current  student  body,  in  order  that  their  fees  might  be  used  to  provide 
a  better  basis  for  a  body  of  students  that  would  come  along  in  the  future.  Didactic 
lectures  were  given  in  1890,  to  pay  for  a  building  in  which  laboratory  instruction 
could  be  given  in  1900.  As  conditions  improved,  one  laboratory  was  put  into  opera- 
tion, while  a  fee  surplus  was  accumulated  to  install  a  second.  Before  the  day  of 
medical  school  support  by  endowment  or  taxation,  such  procedure  compared  very 
favorably  indeed  with  the  more  common  practice  of  doing  nothing  for  the  student 
of  to-day  and  as  little  as  possible  for  the  student  of  to-morrow.  The  point  now  to 
aim  at  is  the  development  of  the  requisite  number  of  properly  supported  institutions 
and  the  speedy  demise  of  all  others. 

In  varying  degrees,  contented  acceptance  of  these  conditions  goes  along  with  the 
survival,  however  insidiously,  of  the  notion  that  medical  education,  whatever  else  it 
may  be,  is  something  of  a  business,  too.  It  is  questionable  whether  this  notion  can  ever 
be  uprooted,  so  long  as  several  competing  schools  in  the  same  or  in  adjacent  towns 
solicit  patronage  that  can  never  again  be  sufficient  in  volume  to  satisfy  them  all. 
The  essence  of  a  business  transaction  consists  in  spending  less  in  producing  an  article 
than  is  paid  for  it  over  the  counter,  how  much  less  depending  now  on  the  proximity 
and  competitive  eagerness  of  other  dealers,  now  on  the  wariness  and  number  of  the 
customers.  It  matters  not  that  in  this  instance  the  article  is  education,  the  counter 
the  registrar's  latticed  window,  the  profit  going  in  extreme  cases  in  large  sums  into 
a  doctor's  pocket,  in  the  best  cases  in  smaller  sums  into  bricks  and  microscopes.  If, 
in  other  words,  medical  education  is  a  social  function,  it  is  not  a  proper  object  for 
either  institutional  or  individual  exploitation.  Society  ought  to  provide  means  for 
its  support  according  to  the  best  light  obtainable ;  and  the  law  should  make  it  im- 
possible for  any  person  or  institution  to  engage  in  it  on  any  other  than  the  best 
terms  that  society  is  in  position  to  enforce.  Great  departures  from  this  principle  were 
at  one  time  inevitable:  the  country  was  bound  to  have  doctors;  it  had  to  take  them 


128  MEDICAL  EDUCATION 

as  it  could  get  them.  They  need  never  have  been  so  badly  trained  as  most  of  them 
were.  But  on  that  point  it  is  useless  to  dwell.  Important  for  us  it  is  to  ascertain 
whether  in  this  year  of  grace,  1910,  it  is  still  necessary  to  put  up  with  schools  that 
are  seriously  defective;  and  if  so,  to  what  extent,  and  how  much  longer. 

What  does  it  really  cost  to  carry  on  a  medical  school  that  construes  its  duty  in 
social  terms?  Initial  investment  may  be  put  to  one  side.  That,  the  college  income 
cannot  furnish;  fees  cannot  provide  buildings  and  equipment  in  the  first  place,  or  pay 
for  them  subsequently  in  instalments.  The  medical  school  must  start  with  an  ade- 
quate plant,  laboratory  and  clinical,  debt  free.  The  value  of  these  plants  may  vary 
within  very  wide  limits;  size,  style,  the  ratio  of  teaching  to  research,  all  bear  on  the 
problem  of  initial  cost.  In  a  measure  it  is  a  question  of  taste,  how  much  one  will  ex- 
pend on  buildings  and  equipment.  Essential,  however,  to  every  venture  are  class-rooms 
with  the  essential  teaching  paraphernalia,  class  laboratories  in  each  of  the  sciences 
with  individual  equipment,  private  quarters  with  requisite  appurtenances  for  each 
member  of  the  teaching  staff.  These  facilities  cannot  be  dispensed  with  because  the 
numbers  to  be  handled  are  small.  The  several  items  may  be  scaled  down,  but  they 
do  not  disappear.  Fee  income,  confessedly  inadequate  to  keep  such  a  plant  running, 
cannot  be  called  on  to  provide  it.  The  plant,  therefore,  is  taken  for  granted  before 
we  even  begin  to  consider  what  it  costs  to  teach  medicine. 

For  the  sake  of  simplicity  we  shall  continue  the  demarcation  between  laboratory 
and  clinical  branches.  At  present  the  cost  of  maintaining  the  hospital  is  not  usually 
a  school  encumbrance.  Whether  or  not  it  ought  to  be  must  be  decided  as  the  case 
arises.  Western  Reserve  is  in  position  to  avoid  the  expense;  the  University  of  Michi- 
gan must  carry  it.  In  general,  the  school  obligation  on  this  point  has  been  shirked. 
The  intolerable  compromises  described  in  the  preceding  chapter  are  employed  in  con- 
sequence. Nothing  will  perhaps  go  further  towards  destroying  superfluous  schools  or 
preventing  new  ones  than  correct  ideas  as  to  necessary  hospital  conditions.  It  is  quite 
impossible  that  most  schools  should  either  possess  their  own  hospitals  or  effect  a  satis- 
factory relation  with  hospitals  belonging  to  other  people.  At  the  moment,  possession 
rather  than  diplomacy  seems  in  most  places  to  furnish  the  only  satisfactory  solution, 
— and  possession  necessitates  an  immense  increase  of  the  school  budget.  Meanwhile, 
this  point  will  not  be  obscured  by  provisional  separation  of  the  two  budgets ;  for  this 
manner  of  presentation  an  additional  reason  is  found  in  the  fact  that,  to  a  varying 
extent,  the  hospital  may  be  made  to  carry  itself  without  derogating  from  its  peda- 
gogical purpose. 

A  schematic  outline  of  the  laboratory  years  calls  for  at  least  five  departments, 
(1)  anatomy,  (2)  physiology  and  pharmacology,  (3)  chemistry,  (4)  pathology,  (5)  bac- 
teriology and  hygiene,  subject,  within  limits,  to  rearrangement.  The  ultimate  cost  of 
the  entire  school  will  not  be  greatly  affected  by  such  redistribution.  In  their  internal 
economy  the  departments  will  follow  the  same  general  lines.  There  will  be  a  profes- 
sor, devoting  himself  wholly  to  teaching  and  research,  and  in  position  to  do  both; 


FINANCIAL  ASPECTS  129 

assistants  varying  in  number  with  the  size  of  the  classes  and  the  extent  to  which  the 
institution  is  minded  to  encourage  original  activity ;  a  departmental  helper  attached 
to  each  department ;  preferably,  too,  a  technician  and  a  mechanic,  who  will,  however, 
in  the  end  more  than  save  their  cost. 

The  budget  of  a  department  thus  organized  in  a  medical  school  of,  say,  250  stu- 
dents, favorably  situated,  would  assign  $3000  to  $5000  a  year  to  its  head,  $2000  to 
$2500  to  a  first  assistant,  $1000  to  $2000  to  additional  assistants,  $750  to  a  helper, 
and  $2500  to  $5000  to  maintenance,  including  books,  new  apparatus,  material,  ani- 
mals, etc.  The  total,  ranging  from  $9250  to  $15,250,  still  omits  a  proportionate 
share  of  the  general  overhead  expense  of  administering  the  institution.  A  university 
department  in  one  of  the  fundamental  medical  sciences,  none  too  elaborately  pro- 
vided, cannot,  then,  on  the  average  be  effectively  maintained  for  less  than  $10,000  to 
$15,000  per  annum.  At  the  moment,  of  course,  the  departments  are  not  all  equally 
expensive.  Anatomy  and  pathology  cost  more  than  pharmacology  and  bacteriology. 
But  the  average  is  not  thus  seriously  disturbed ;  for  the  former  will  extend  above  the 
line  as  much  as  the  latter  can  be  reduced  below  it.  All  of  them,  as  they  are  devel- 
oped, tend  to  cost  more.  Where  the  sum  named  has  not  yet  been  reached,  the  ten- 
dency towards  it  is  unmistakable.  It  is,  of  course,  true  that  fairly  good  instruction  is 
at  times  furnished  more  cheaply.  In  the  small  two-year  schools  situated  in  small 
towns,  the  professors  receive  less,  sometimes  much  less,  than  the  sums  stated;  and  the 
expense  of  maintenance  does  not  at  times  exceed  a  few  hundred  dollars  per  annum. 
But  these  departments  cannot  continue  on  this  makeshift  basis:  they  are  now  manned 
by  young  men,  who,  finding  themselves  doomed  to  routine  and  sterility,  begin  fight- 
ing at  once  to  get  away.  The  teacher  who  is  content  under  such  circumstances  will 
soon  be  out  of  date;  and  the  instruction,  however  conscientious,  will  be  decidedly 
limited  in  range.  To  live,  these  departments  must  be  much  more  liberally  supported; 
and  in  the  small  two-year  schools  where  this  has  been  the  case — notably  at  Cornell 
and  Wisconsin — the  departmental  budgets  correspond  pretty  closely  to  our  present 
estimate.  The  organization  of  a  department  of,  say,  physiology  on  the  minimum 
basis  of  efficiency,  for  25  students  or  less,  would  require,  after  providing  the  initial 
plant,  $3000  for  the  professor,  $1000  for  his  assistant,  $750  expense  on  the  score  of 
material  for  class  use,  $250  to  keep  some  little  research  going,  $300  for  books  and 
periodicals,  $600  for  a  janitor, — a  total  of  $5900  for  the  routine  teaching  of  a  few 
students  under  undesirable  limitations.  As  it  is  clear  that  there  is  no  justification 
just  now  for  the  existence  of  medical  schools  that  are  incapable  of  greatly  bettering 
the  type,  it  follows  that  schools  unable  or  indisposed  to  spend  the  requisite  sums  lack 
a  valid  reason  for  being.  We  may  then  assume  that  the  five  departments  of  a  properly 
organized  medical  school,  capable  of  handling  125  students,  in  its  first  two  years  can 
hardly  be  properly  sustained  on  a  total  budget  of  less  than  from  $50,000  to  $75,000 
annually.  If,  now,  the  student  pays  $150  a  year  for  tuition,  there  will  be  an  annual 
deficit  ranging  from  $31,250  to  $56,250  a  year.  Not  all  the  medical  schools  that  are 


ISO  MEDICAL  EDUCATION 

alive  to  their  responsibility  are,  as  we  shall  see,  at  this  moment  able  to  provide  on  this 
scale  for  each  of  the  fundamental  departments;  but  they  are  in  no  doubt  that  these 
departments  need  such  support;  and  they  are  straining  every  effort  to  procure  it  for 
them.1 

On  the  clinical  side,  the  problem  is  more  complicated.  We  have  seen  that  the  re- 
lation of  the  medical  school  to  its  hospital  must  be  of  the  same  kind  as  its  relation 
to  its  laboratories.  But  laboratories  exist  only  for  school  purposes;  the  hospital  dis- 

1 A  comparison  of  the  estimates  above  given  with  corresponding  budgets  in  German  universities  is 
highly  suggestive.  Despite  the  fact  that  the  cost  of  apparatus,  supplies,  etc.,  is  much  lower  in  Germany 
than  here,  the  sums  spent  in  various  universities  on  laboratory  maintenance  are  as  follows : 
KONIGSBERG  (170  medical  students)  BBESLAU  (189  medical  student*) 

Anatomy         16,349  marks  Anatomy        26,618  marks 

Pathology        9,860  Pathology       14,932 

BERLIN  (1107  medical  students)  GOTTINGEN  (189  medical  students) 

Anatomy        57,436  marks  Anatomy        19,850  marks 

Physiology     89,766  Physiology       9,606 

(From  Etat  des  Ministeriums  der  Unterrichts-  und  Medizinal  Angelegenheiten,  1909,  Beilage  6.) 

Still  more  significant  is  the  ratio  between  expenditure  for  salaries  and  that  for  laboratory  main- 
tenance, and  the  steady  encroachment  of  the  latter :  out  of  every  100  marks  spent  in  German  uni- 
versities, there  went  in 

1868        45.95  marks  to  salaries  37.07  marks  to   laboratories 

1878        41.94  40.46 

1888        36.00  47.18 

1902         29.46  53.77      " 

1906        27.93  55.45 

(From  Preussische  Statistik,  204:  Slatistik  der  preuuischen  Landes  Universitdten,  1908,  p.  7.) 

Finally,  the  actual  sums  spent  on  salaries  and  laboratories  respectively  tell  the  same  significant 
story: 
Total  expenditure  in  Prussian  universities  in 

1868        1,786,108  marks  for  salaries  1,440,955  marks  for  laboratories 

1878    2,959,187  2,959,103 

1888    3,305,125  4,331,649 

1898    3,499,785  6,094,316 

1906    4,308,980   "  8,554,581   " 

(Ibid.,  p.  14.) 

That  is,  in  38  years,  total  salaries  have  increased  141  per  cent,  total  laboratory  expense,  490  per  cent. 
In  the  same  period,  the  total  attendance  of  medical  students  in  the  same  universities  has  risen  113 
per  cent  (from  2771  in  winter  semester,  1868,  to  5903,  winter  semester,  1906). 

Paulsen  (German  Universities,  translated  by  Thilly,  p.  219,  note)  quotes  from  the  Rector's  Address 
of  Adolph  Wagner  in  1896 : 

"Expenditures  for  salaries  and  institutes  in  the  University  of  Berlin  show  the  following  growth : 
Year  Salaries  Institutes 

1811  116,550  marks  (71.8  per  cent)  39,294  marks  (24.0  per  cent) 

1834  193,650  (64.6   "        "  )  78,434  (26.2   "        '    ) 

1880  321,000  (52.8   "        "   )          267,000  (40.1    '        '    ) 

1896-7  865,000  (30.9    "        "   )       1,481,000  (52.9    "        '    )" 

All  the  seminaries  in  the  mental  sciences  (there  are  18)  cost  17,650  marks  annually;  the  15  natural- 
scientific  institutes  and  collections  cost  379,798  marks;  the  10  medical-scientific  institutes  190,054 
marks;  the  10  clinical  institutes,  617,691  marks. 

The  publications  of  the  Prussian  government  mentioned  above  are  models,  which  we  would  do  well 
to  adopt.  They  enable  us  to  follow  in  minute  detail  the  educational  developments  of  the  last  seventy- 
five  years,  with  their  social  implications.  The  American  student  of  similar  problems  deals  with  chaos. 
It  is  difficult  to  obtain  definite  and  complete  statements  from  any  one  institution ;  and  quite  impos- 
sible to  compare  data  from  several  institutions  without  exhaustive  inquiry  by  way  of  ascertaining 
whether  they  cover  the  same  ground.  The  German  statistics  prove  clearly,  however,  the  point  at 
issue,  i.e.,  the  rapidly  increasing  cost  of  properly  organized  medical  education. 


FINANCIAL  ASPECTS  131 

charging  simultaneously  a  philanthropic  office  may,  as  we  have  seen,  be  provided  for 
independently  of  school  funds  and  yet  be  as  intimately  a  part  of  the  educational  or- 
ganization as  if  teaching  were  its  main  purpose.  The  school  will  invariably  have  to 
equip  and  maintain  its  laboratories;  the  hospital  may  be  separately  financed  without 
burden  to  the  medical  school.  Further,  the  initial  cost  of  the  hospital  establishment 
may  vary  within  large  limits :  a  plain,  but  serviceable  structure,  capable  of  accommo- 
dating 200  patients,  with  proper  teaching  facilities,  may  be  erected  for  a  few  hundred 
thousand  dollars;  or  it  may  cost  millions.  The  cost  of  maintenance  also  fluctuates 
considerably  according  to  situation  and  scale  of  support.  In  the  city  of  New  York,  it 
is  roughly  estimated  that  it  takes  $1000  to  maintain  one  bed  for  one  year;  a  200  bed 
hospital  may  thus  readily  involve  an  annual  expenditure  of  $150,000  and  upwards. 
This  sum  may  be  reduced  by  profits  derived  from  pay  patients,  or  by  small  contribu- 
tions from  charity  patients.  The  extent  to  which  the  provision  of  proper  clinical 
opportunities  falls  upon  the  medical  school  varies,  then,  from  place  to  place.  It  is 
therefore  not  included  in  the  schematic  school  budget  we  are  preparing;  but  it  is 
important  to  emphasize  clearly  that  where  independent  endowment  or  state  support 
does  not  furnish  the  medical  school  with  a  hospital  in  which  it  is  thoroughly  at  home, 
the  burden  falls  at  once  upon  the  school.  The  substitutes,  makeshifts,  and  compromises 
now  so  widely  employed  in  the  United  States  do  not  relieve  the  medical  schools  of 
their  responsibility. 

From  the  standpoint  of  the  medical  school,  it  is  perhaps  immaterial  how  its  hos- 
pital is  supported.  But  it  would  be  unfair  not  to  point  out  briefly  in  passing 
that  certain  larger  considerations  give  great  importance  to  the  source  of  hospital  sup- 
port. The  hospital  in  the  United  States  is  not  necessarily  privately  managed  because 
privately  supported,  or  publicly  managed  because  publicly  supported :  it  may  be  pri- 
vately managed,  even  though  in  large  measure  publicly  supported.  The  teaching  hos- 
pitals connected  with  the  Philadelphia  schools  and  with  the  proprietary  schools  of 
Baltimore  are  of  this  description.  In  respect  to  management  they  are  private  con- 
cerns; but  they  have  received  large  lump  subsidies  from  the  state  for  both  buildings 
and  support.  It  is  not  the  sole  objection  to  this  policy  that  it  strengthens  proprie- 
tary medical  schools,  though  that  is  surely  a  legitimate  criticism.  More  serious  is  the 
general  demoralization  that  log-rolling  always  entails.  Schools  and  hospitals,  com- 
peting in  all  other  matters,  join  hands  in  assaulting  the  state  treasury;  for  coopera- 
tive action  increases  the  total  largess  to  be  divided.  The  state  or  city  can  indeed 
legitimately  aid  medical  education  by  completely  handing  over  to  high-grade  medi- 
cal schools  the  ward  service  in  hospitals  financially  managed  by  the  proper  state  or 
municipal  authorities.  The  public  interest  would  be  promoted,  not  injured,  if,  for 
example,  Cornell,  Columbia,  and  New  York  University  were  each  left  in  unfettered 
possession  of  its  division  at  Bellevue  (New  York) ;  there  is  no  possible  source  of  de- 
moralization there.  The  Pennsylvania  plan,  however,  tends  to  transfer  the  making  of 
appropriations  and  the  accounting  for  the  same  from  the  hands  of  state  officials  to 


132  MEDICAL  EDUCATION 

private  parties  whose  common  interest  it  is  to  increase  appropriations  and  to  reduce 
oversight.1  The  size  of  the  appropriation  is  determined  to  greater  or  less  degree  by 
the  violence  of  the  onset  There  is  no  fixed  relation  between  the  charity  work  done 
and  the  amount  asked  or  secured.*  In  pursuance  of  that  policy  the  state  of  Pennsyl- 
vania last  year  granted  out  of  the  public  treasury  to  private  and  semi-private  hos- 
pitals $4,404,500. 

However  the  hospital  and  dispensary  are  supported,  the  teaching  budget  of  the 
clinical  years  is  necessarily  a  charge  upon  the  funds  of  the  medical  school.  The  pro- 
fessor of  medicine  in  the  medical  school  will  be  physician-in-chief  to  the  hospital; 
surgeon,  obstetrician,  pediatrist,  will  likewise  occupy  the  same  dual  relation.  The 
university  hospital  will  be  their  laboratory ;  their  salaries  will  protect  them  against 
the  distractions  of  successful  practice,  be  that  practice  general  or  consultant, — for 
a  thriving  consultation  business  may  prove  just  as  fatal  to  scientific  productivity  as 
any  other  form  of  immersion  in  routine.  The  clinical  departments  must  embody  the 
same  ideals  as  pathology  or  physiology  in  respect  to  teaching  and  research;  they 
require,  then,  the  same  organization  and  support.  The  laboratory  service  must  be  ex- 
tended for  them.  For  the  investigator  in  internal  medicine  needs  not  only  a  clinic, 
but  a  laboratory,  in  whose  activities  the  bedside  problem  and  the  fundamental 
sciences  are  brought  together.  The  professors  of  pathology,  physiology,  physiologi- 
cal chemistry,  work  on  broad  lines.  The  clinician  applies  what  he  obtains  from  them 
to  problems  that  are  narrower  in  compass.  Neither  the  clinical  laboratories,  where 
routine  examinations  are  carried  on,  nor  the  fundamental  scientific  laboratories, 
serve  precisely  the  needs  of  the  investigating  clinician,  though  the  latter  are  in  the 
most  intimate  cooperation  with  him. 

What  may  be  called  the  theory  of  virtual  endowment  deserves  a  word  at  this 
point.  Let  us  suppose  that  ten  practitioners  give  their  professorial  services  gratis. 
Undoubtedly  their  ethical  position  is  better  than  that  of  practitioner  teachers  who 
draw  dividends.  They  contend,  however,  that  their  services  constitute  an  endowment. 
Paid  teachers  would  get,  say,  $3000  each.  The  $30,000  saved  represents  five  per  cent 
on  $600,000.  It  is  argued  that  the  school  is  just  where  it  would  be  if  it  had  an  en- 
dowment of  something  more  than  a  half-million.  Sanguine  calculators  of  this  type 
occasionally  run  the  virtual  endowments  up  to  two  or  three  millions.  But  virtual 
endowment  is  a  poor  substitute  for  good  bonds.  The  volunteer  teacher  may  begin 
well ;  but  as  between  teaching  and  practice,  the  former  must  always  get  the  worst  of 
it.  Slipshod  dispensaries,  imperfect  hospital  records,  general  clinical  barrenness,  tell 
the  tale. 

1  Experts  are  of  one  mind  as  to  the  viciousness  of  this  policy.  See,  for  example.  Report  on  Subtidiet, 
National  Conference  of  Charities  and  Corrections,  hem  at  Washington,  D.C.,  May  9-15,  1901. 

•The  amounts  secured  vary  from  12  cents  to  $2  a  day  for  free  patients,  according  to  the  efficacy  of 
the  hospital  "pull."  In  New  York  city  "  pull "  is  eliminated :  the  hospital  is  paid  a  fixed  sum  for  ser- 
vice rendered.  Nevertheless,  even  this  method  of  procedure  may  have  unfortunate  educational  con- 
sequences,—for  it  enabled  the  Brooklyn  Post-Graduate  Medical  School  to  start. 


FINANCIAL  ASPECTS  133 

The  modern  medical  establishment  that  spends  $50,000  or  $75,000  upon  its  fun- 
damental laboratories  will,  if  it  is  to  be  equally  productive  in  clinical  medicine, 
spend  an  equal  sum  on  teaching  and  investigation  during  the  latter  two  years, — 
quite  apart  from  the  current  maintenance  of  hospital  and  dispensary.  That  is  to 
say,  $100,000  to  $150,000  will  be  required  at  the  start  to  pay  the  minimum  cost  of 
a  four-year  school  of  medicine  accommodating  250  students  and  consistently  organ- 
ized along  sound  lines  on  both  laboratory  and  clinical  sides.  The  outlay  will  increase, 
not  decrease,  as  the  school  grows,  not  in  number,  but  in  scope  and  power.  The  pro- 
posed budget  may  look  formidable  just  now,  when  compared  with  the  scant  provision 
that  has  been  generally  made  for  medical  education  in  this  country  under  men  many 
of  whom  have  had  no  real  appreciation  of  what  good  medical  training  is,  or  costs; 
but  as  public  sentiment  and  educational  intelligence  develop,  the  suggested  scale  will 
appear  not  only  modest,  but  insufficient. 

The  fees  received  from  such  a  student  body  would  amount  to  some  $40,000;  so 
that  it  may  be  fairly  estimated  that  in  such  an  institution  fees  will  at  the  utmost 
pay  little  more  than  one-third  of  the  expense,  provided  that  proper  hospital  and 
dispensary  facilities  are  already  supported  by  endowment  or  otherwise.  A  com- 
forting notion  is  prevalent  that  "in  time"  this  proportion  will  rise,  and  that  losses 
in  attendance  due  to  elevation  of  standards  will  eventually  be  "  made  up."  There  is 
no  warrant  for  this  belief.  Institutions  which  have  always,  or  long,  operated  on  a 
high  standard,  and  thus  command  an  established  public,  find  that  expense  tends  to 
increase  more  rapidly  than  fee  income.  They  persistently  seek  additional  funds  that 
may  enable  them  to  push  ahead.  The  number  of  high  standard  schools  supported 
will  tend  to  be  in  some  definite  relation  to  the  public  need;  there  will  be  no  such 
disproportion  between  number  and  need  on  a  high,  as  there  has  been  on  the  low, 
basis.  In  other  words,  the  total  enrolment  will  shrink;  it  will  tend  to  concentrate 
in  fewer  schools.  Under  these  circumstances  schools  which  have  long  enjoyed  a  com- 
paratively low-grade  patronage  must  cut  loose  from  their  past,  and  begin  to  culti- 
vate a  new  clientele.  They  will  probably  make  slow  headway  in  recovering  from  the 
initial  shock.  Most  of  them  must  expire  or  "merge"  before  their  independent  salva- 
tion can  possibly  be  worked  out.  Our  conclusion  is  that  established  schools,  secure  of 
their  public  on  a  sound  basis,  may  count  on  fees  to  the  extent  of  one-third  to  one- 
half  of  the  expenditure  required  to  conduct  a  good  school  of  modern  medicine;  and 
that  as  the  department  becomes  more  homogeneously  developed,  the  fees  will  tend 
to  do  even  less. 

It  is  interesting  to  compare  this  hypothetical  budget  as  a  whole,  and  by  separate 
departments,  with  the  actual  outlay  of  our  best  schools.  The  Johns  Hopkins  most 
nearly  represents  desirable  conditions;  for  there  a  teaching  hospital  belonging  to 
the  medical  school  is  supported  by  adequate  and  separate  endowment,  so  that  clinical 
facilities  impose  no  burden  on  the  funds  of  the  medical  school  proper.  Moreover, 
there  from  the  first  clinical  teachers  have  been  salaried  and,  in  a  measure,  withdrawn 


184  MEDICAL  EDUCATION 

from  general  practice.  The  actual  cost  of  conducting  the  Johns  Hopkins  Medical 
School,  with  297  students,  is  something  over  $100,000  a  year,  not  including,  how- 
ever, the  salaries  of  clinical  professors,  which  are  in  this  case  paid  out  of  the  hospital 
funds.  Including  these,  the  total  outlay  would  considerably  exceed  our  estimate. 
Tuition  fees  are  about  one-half  of  this  amount.  The  Harvard  budget  runs  higher, 
$251,389,  much  more  than  double  the  income  in  fees  from  its  285  students;  Michigan, 
with  389  students,  spends  $83,000  on  its  department  of  medicine  and  surgery,  and 
$70,000  more  on  the  university  hospital;  Columbia,  with  312  students,  requires 
$239,072  for  the  College  of  Physicians  and  Surgeons,  including  the  Sloane  Maternity 
Hospital  and  the  Vanderbilt  Clinic;  Cornell  (207  students)  expends  $209,888  at 
New  York  and  $32,840  more  at  Ithaca,  and  gets  back  $24,410  in  fees.  The  Toronto 
(592  students)  medical  budget  is  about  $85,000,  as  against  $64,500  received  in  fees; 
McGill  (328  students),  $77,000,  as  against  $43,750  received  in  fees;  the  University 
of  Minnesota,  $71,336,  as  against  $16,546  received  in  fees.  More  modest  establish- 
ments, working  towards  the  same  ideals,  make  a  similar  exhibit:  eighteen  years  ago 
the  total  budget  of  the  Yale  Medical  School  was  $10,000^  it  is  now  $43,311,— three 
times  the  amount  received  in  tuition  fees  and  confessedly  inadequate  to  the  aspira- 
tions and  capacity  of  the  medical  faculty.  Cornell  spends  at  Ithaca,  on  a  two-year 
course,  $32,840,  not  including  the  cost  of  heating,  lighting,  administration,  etc. 

Few  of  these  institutions  have  developed  all  departments  equally.  Even  the  labo- 
ratory branches  are  not  as  yet  all  of  the  same  type.  Relatively  few  even  of  the  best 
schools  are  able  to  cultivate  pharmacology  to  any  considerable  extent ;  the  same  is 
true  of  preventive  medicine.  On  the  clinical  side,  makeshifts  of  which  we  cannot  be 
too  impatient  are  all  but  universal.  In  general,  even  where  intelligent  ideals  prevail, 
resources  do  not  suffice  for  an  all-round  organization.  Wherever  a  department  has 
been  acceptably  cared  for,  the  expenditure  is  apt  to  exceed  our  schematic  estimate  :a 
Johns  Hopkins  now  spends  $16,750  a  year  on  anatomy,  $14,171  on  pathology  (not 
counting  $4791  spent  on  the  clinical  laboratory),  $13,246  on  physiology  and  phy- 
siological chemistry.  Columbia  spends  $29,259  on  anatomy,  $18,400  on  pathology,8 
$17,838  on  physiology.  Cornell  (New  York)  spends  $37,000  on  pathology,*  histology, 
and  bacteriology,  $15,895  on  anatomy,  $14,940  on  physiology.  These  appropriations 
are  not  extravagant.  On  the  contrary,  they  are  closely  approached — sometimes  ex- 
ceeded— wherever  modern  methods  are  effectively  employed:  at  Ithaca,  Cornell  (18 
students)  spends  $9500  on  anatomy  and  $13,500  on  physiology  and  pharmacology; 
New  York  University  (408  students)  spends  $15,000  on  pathology;  Washington 

1  Graham  Lusk:  "Medical  Education,"  Journal  Amor.  Med.  Ann.,  vol.  Hi.  p.  1230. 

1  The  budgets  that  follow  are  not  exactly  comparable,  for  the  lines  are  not  always  drawn  in  exactly 
the  same  way.  Nevertheless  they  represent  nearly  enough  the  same  thing  to  illustrate  the  point  under 
discussion.  Unfortunately  college  accounting  does  not  as  yet  enable  us  to  say  how  much  goes  into 
ordinary  undergraduate  teaching,  how  much  into  research,  etc. 

*  Including  clinical  pathology,  $26,800. 
4  Excluding  clinical  pathology. 


FINANCIAL  ASPECTS  135 

University,  St.  Louis  (178  students),  spends  $9640  for  anatomy,  $8550  for  physio- 
logy and  pharmacology;  the  University  of  Wisconsin  (49  students)  spends  SI 0,000 
for  anatomy  and  $8100  for  physiology.  Anatomy  costs  the  University  of  Michigan 
$14,300  a  year,  and  the  University  of  Iowa  $13,525.  Champions  of  cheapness  allege 
that  large  sums  are  needed  only  for  research,  where  medicine  is  taught  to  college 
graduates  who  afterwards  practise  in  large  cities ;  but  Michigan  and  Iowa  spend  these 
sums  in  behalf  of  high  school  boys  who  after  graduation  from  the  medical  school  re- 
turn to  the  simple  surroundings  amidst  which  they  grew  up.  New  York  University 
operates  also  with  high  school  boys,  and  is  mainly  a  teaching  school.  Where  clinical 
medicine  is  on  the  proper  basis,  the  same  result  emerges:  at  Tulane,  for  example 
(439  students),  the  department,  recently  reorganized  on  modern  lines,  requires  $9100 
for  its  support.  The  University  of  Michigan  uses  $7830  in  medicine,  $9405  in 
surgery.  Every  one  of  the  important  subjects  must  of  course  very  soon  be  pro- 
vided on  an  adequate  scale;  for  in  every  acceptable  medical  school,  though  large 
individual  variations  must  occur,  the  movement  to  treat  the  main  clinical  divisions 
similarly  will  not  stop.  A  simple  process  of  multiplication  will  then  give  the  mini- 
mum cost  of  maintaining  a  medical  establishment  in  which  all  the  essential  sub- 
jects are  adequately,  even  though  not  homogeneously,  developed.  Endowment 
or  taxation  alone  can  meet  this  burden, — and  endowment  and  taxation  are  feasi- 
ble only  if  medical  education  is  carried  on  not  only  in,  but  by  the  university.  For 
of  course  a  medical  school  supported  by  fees  is  just  as  fettered  inside,  as  it  would 
be  outside,  the  university.  Its  ideals  may  be  higher ;  its  fee  income  may  be  more  in- 
dependently expended.  But  in  no  case  are  the  fees  adequate  to  support  all  the  es- 
sential departments  on  a  substantial  basis.  As  a  rule,  these  schools  "feature"  one  or 
two  branches ;  the  others  pine.  The  best  developed  departments  show  what  all  ought 
to  be:  pathology  at  New  York  University,  anatomy  at  Jefferson  Medical  College, 
are  really  strong  departments;  they  belong  to  institutions  dependent  on  fees;  but  to 
provide  them,  other  departments  must  be  denied  anything  like  equal  opportunity  to 
expand. 

Of  course  it  is  not  to  be  supposed  that  the  most  expensive  teaching  is  the  best; 
that  a  department  that  costs  $20,000  is  necessarily  twice  as  good  as  one  that  spends 
$10,000;  it  may  be  both  scientifically  and  pedagogically  inferior.  It  remains  true, 
however,  that  in  general  the  equipment  and  conduct  of  laboratories  are  costly ;  that 
professorial  salaries  are  rising;  that  a  productive  teacher  needs  competent  assistants, 
expensive  apparatus,  material,  etc.,  and  a  certain  margin,  in  case  an  unforeseen  turn 
necessitate  an  unusual  outlay.  The  scientist  financially  hampered  so  as  to  be  in- 
capable of  following  out  surprises  may  miss  the  most  valuable  result  of  his  tedious 
labors. 

Important  is  it  to  observe  that  the  expense  does  not  diminish  pan  passu  with  the 
attendance.  The  formation  of  two-year  schools  has  recently  proceeded  apace,  many 
of  them  feebly  equipped  and  poorly  sustained;  their  initial  plant  costs  little;  their 


1S6  MEDICAL  EDUCATION 

total  budgets  are  but  a  few  thousand  dollars.1  A  few  dollars  are  expended  for  books; 
animals  are  provided  in  a  gingerly  manner;  pathological  material  is  small  in  amount, 
and  comes  as  a  gratuity  from  distant  schools  whose  needs  have  been  previously  sup- 
plied; apparatus  barely  suffices  for  routine  work;  no  helpers  relieve  the  single  de- 
partmental teacher  of  menial  drudgery.  These  schools  are  of  course  scientifically 
sterile;  as  such,  they  must  rapidly  become  antiquated,  for  they  are  situated  in  out- 
of-the-way  places  and  their  staff  has  but  little  intercourse  with  active  centers.  It 
seems  hardly  justifiable  to  start  such  ventures  merely  to  meet  institutional  com- 
petition. The  two-year  school  can  doubtless  make  good  where,  as  in  Wisconsin, 
liberal  support  overcomes  at  many  points  the  defects  due  to  isolation;  the  heavy 
charges  incurred,  however,  ought  to  be  seriously  pondered  by  those  whose  less  ample 
means  forbid  anything  like  so  adequate  an  appropriation. 

It  is  now  clear  that  medicine  cannot  be,  and  is  not,  properly  taught  on  the  basis 
of  receipts.  We  have  at  this  date  30-odd  schools,  all  university  departments,  whose 
annual  budgets  call,  for  sums  considerably  in  advance  of  their  receipts  from  fees.  As 
these  institutions  will  in  number  and  facilities  undoubtedly  soon  be  equal  to  the 
task  of  producing  physicians  enough  to  supply  the  need,  the  coil  is  tightening 
around  schools  not  yet  in  position  to  devote  even  all  their  fees  to  instruction.  Well 
known  institutions  can  still  be  cited,  whose  instruction  as  offered  costs  the  school 
less  than  the  fees  paid  in, — a  balance  being  available  for  buildings,  improvements, 
or  for  debt  originally  incurred  for  plant.  Large  receipts  mean  in  most  instances* 
low  standards, — standards  below  the  four-year  high  school  basis.  In  order  to  secure 
a  balance,  economies  must  be  effected,  as  has  been  already  pointed  out,  at  the  expense 
of  teaching,  by  inadequate  equipment,  uneven  development,  lack  of  full-time  profes- 
sors, reliance  upon  necessarily  incompetent  student  assistants,  absence  of  helpers, 
employment  of  volunteers  in  the  dispensary,  etc.  Tufts  College  Medical  School,  with 
an  income  of  859,093,  is  paying  off  in  annual  instalments  a  debt  incurred  for  the 
building  it  now  occupies;  Jefferson  Medical  College,  with  receipts  of  SI 02,995,  must 
incidentally  accumulate  a  fund  to  retire  a  large  mortgage.  The  medical  department 
of  Northwestern  University  must  apply  its  surplus  to  the  discharge  of  debts  incurred 
for  buildings  and  plant.  Vanderbilt  University,  having  invested  $83,000  in  a  medi- 
cal department,  compels  the  department  out  of  its  fees  (about  $25,000  a  year)  to 
pay  all  its  own  running  expenses,  something  on  the  original  purchase  price,  and  six 
per  cent  interest  on  the  unpaid  balance.  The  University  of  Maryland,  the  College  of 
Physicians  and  Surgeons  of  Baltimore,  the  Starling-Ohio  (Columbus),  pursue  substan- 
tially the  same  policy. 

1  The  minimum  outlay,  ordinary  working  efficiency  being  considered,  for  a  department  of  physiology 
is  given  on  page  199.  It  is  questionable  whether  just  now  an  institution  is  justified  in  undertaking  the 
work  if  it  is  unable  to  do  more  than  this  minimum.  Only  a  decided  probability  of  increased  resources 
in  the  future  warrants  the  step. 

2  Rush  (Chicago)  is  the  only  exception.  No  other  high  standard  school  contains  over  300  students ; 
most  of  them  have  a  comparatively  small  enrolment 


FINANCIAL  ASPECTS  137 

Of  our  155  medical  schools,  120-odd  depend  on  fees  alone.  Of  these,  there  are  better 
and  worse :  the  former  using  the  fees  as  far  as  they  go  to  provide  either  several  labo- 
ratory branches  decently,  or  two  or  three  well;  the  latter  devoting  but  a  part,  often 
a  small  part,  of  the  fee  income  to  pedagogical  use,  distributing  the  rest  among  the 
teachers,  who  are  in  such  cases  always  practising  physicians. 

The  ethics  of  the  case  are  clear.  Let  us  grant  that  in  the  hope  of  ultimately  get- 
ting to  a  sounder  basis,  it  may  have  been  justifiable  for  the  more  prosperous  fee- 
supported  schools,  whose  total  income  is  large  enough  to  do  something,  to  fight  for 
survival.  Surely  they  were,  and  are,  morally  bound  meanwhile  to  furnish  the  best 
medical  teaching  procurable  with  such  income  as  they  enjoy.  Their  practitioner 
teachers  were  all  the  time  profiting  indirectly  by  their  school  connection;  and  this 
would  suffice,  if  their  motives  were  really  as  altruistic  as  is  commonly  alleged. 
Meanwhile,  laboratories  can  be  kept  decent  and  laboratory  teaching  can  as  a  rule  be 
thorough  only  if  full-time  instructors  are  employed.  These  teachers  have  no  income 
but  their  salaries.  The  medical  school  must  therefore  devote  its  fees  primarily  to 
paying  them  and  to  giving  them  the  necessary  facilities.  Though  the  fee-supported 
school  do  this  unreservedly,  it  will  none  the  less  omit  part  of  its  duty,  because  fees  can- 
not support  a  complete  set  of  laboratories  efficiently  organized.  The  school  is  therefore 
not  justified  in  cutting  out  one  or  more  of  its  possible  laboratories  in  order  to  pay  its 
clinical  teachers.  It  must  not  only  use  its  fees  to  pay  for  the  right  kind  of  laboratory 
instruction,  but  it  must  organize  as  many  such  laboratories  as  fees  will  support  before 
paying  anything  to  the  clinical  teachers,  who  profit  indirectly  nevertheless.  A  school 
may  not  be  justified  in  existing  even  on  this  basis;  that  is,  if  the  demand  for  doctors 
can  be  met  by  institutions  that  can  do  better  for  their  students,  there  is  no  need  to 
put  up  with  even  so  altruistic  a  compromise.  Surely  an  institution  that  is  not  will- 
ing to  do  so  much  as  this  has  absolutely  no  defense  unless  a  section  is  so  hard  run 
for  doctors  that  it  must  take  them  on  any  terms  upon  which  they  can  be  procured. 
Such  is  not  the  case  at  this  writing  in  any  part  of  the  United  States  or  Canada.  The 
younger  men  utilized  in  the  dispensary  ought  probably  to  be  treated  on  the  same  basis. 
For  the  dispensary  is  usually  turned  over  to  young  men  still  struggling  for  a  liveli- 
hood. A  small  annual  stipend  would  go  far  to  get  from  them  the  best  service  they 
are  capable  of  rendering.  To  these  two  purposes  the  fee-supported  school  is  in 
conscience  bound  to  apply  its  income.  As  far  as  fees  reach,  orderly,  even  though 
modest,  scientific  departments  and  a  well  conducted  dispensary  service  should  be  pro- 
vided and  paid  for. 

A  few  schools  have  squarely  met  their  responsibility  in  this  matter,  and  with  re- 
sults that  prove  them  deserving  of  additional  support.  The  medical  department  of 
Syracuse  University  has  a  total  fee  income  of  $28,861,  which  is  spent  on  the  sci- 
entific branches ;  the  plant  is  not  elaborate,  but  it  is  effective,  attractive,  and  con- 
scientiously managed.  Within  less  than  a  year,  the  medical  department  of  the 
University  of  Pittsburgh  has  come  under  complete  university  control.  Prior  to  that 


138  MEDICAL  EDUCATION 

time  it  was  a  highly  prosperous  concern  to  its  managers;  nowhere  in  the  country 
were  worse  conditions  found.  Now,  as  then,  the  school  has  only  its  fees  for  support; 
but  they  have  this  year  gone  into  laboratories  instead  of  into  professorial  pockets: 
with  a  result  that  is  hardly  less  than  a  transformation.  Full-time  professors  of  pa- 
thology, physiology,  and  other  branches  have  brought  order  out  of  chaos.  The  entire 
atmosphere  of  the  institution  has  been  clarified :  students  may  be  found  actually 
studying,  in  the  room  in  which  under  other  conditions  last  year  "four  dozen  wooden 
chairs  were  broken  up  "in  boisterous  horse-play.  The  medical  department  of  Boston 
University,  with  a  total  income  of  $12,762,  makes  a  decent  and  attractive  showing 
in  a  simple  way  in  its  laboratories  of  bacteriology,  pathology,  physiology,  etc. 
Highly  creditable  is  the  record  of  Meharry  Medical  College,  the  colored  school  at 
Nashville ;  for  there  the  teachers,  though  practising  physicians,  are  poor  men :  of  the 
total  income  of  $23,946,  the  salary  list  gets  only  $9665.  A  violent  contrast  is  af- 
forded by  Shaw  University  (Raleigh,  N.  C.),  another  school  for  colored  men,  whose 
teachers  are,  however,  white  physicians:  its  income  from  fees  is  $2846;  a  few  contri- 
butions increase  the  total  income  (not  counting  the  board  of  students)  to  $4721 ; 
the  teachers  just  referred  to  draw  out  $4737.  In  consequence  the  school  has  practi- 
cally no  outfit. 

In  the  majority  of  the  larger  schools  dependent  on  fees,  an  opposite  policy  is  pur- 
sued. The  laboratories  are  slighted  or  starved;  the  dispensary  is  neglected  in  order 
that  dividends  or  salaries,  running  sometimes  as  high  as  $1000,  may  be  paid  to  pre- 
cisely those  faculty  members  who  need  it  least.  The  Albany  Medical  School  — nomi- 
nally affiliated  with  Union  College — has  a  fee  income  of  $20,276.  Associated  with 
it  is  the  Bender  Laboratory,  where  practically  all  its  laboratory  teaching  except 
chemistry  and  anatomy  is  carried  on.  The  school  appropriates  niggardly  sums  to 
provide  for  the  teaching  of  pathology  and  bacteriology  by  the  overworked  and  under- 
helped  chief  of  the  Bender  Laboratory ;  the  laboratory  has  struggled  hard,  and  not 
unsuccessfully,  to  be  productive  at  the  same  time;  but  it  has  accomplished,  whether 
in  teaching  or  in  research,  but  a  fraction  of  what  it  would  have  achieved,  had  not  a 
large  part  of  the  college  receipts  been  distributed  in  sums  approximating  $500  each 
to  fifteen  members  of  the  school  faculty.  At  Buffalo  similar  conditions  exist.  The 
dispensary  is  utterly  neglected ;  some  laboratory  subjects  are  unprovided,  others  are 
slighted,  in  order  that  a  "nominal"  salary  of  $1000  may  be  paid  in  real  money  to 
some  of  the  leading  practitioners  in  the  town.  This  institution  collects  $4608  in 
laboratory  fees  and  spends  $1105  in  carrying  the  laboratories  on.  Brooklyn  fairly 
repeats  Albany.  There  the  Hoagland  Laboratory  relieves  the  Long  Island  College 
Hospital  of  certain  subjects ;  the  rest  are  omitted,  for  the  fees  that  might  furnish 
them  are  distributed  among  well-to-do  clinical  teachers.  Bowdoin,  with  a  total  avail- 
able income  of  $15,230,  appropriates  $200  for  the  maintenance  of  the  bacteriologi- 
cal laboratory,  $50  for  the  physiological  laboratory,  $200  for  chemistry,  and  $200 
for  books,  as  against  $12,225  for  salaries  to  men,  not  one  of  whom  gives  his  whole 


FINANCIAL  ASPECTS  139 

time  to  medical  education.  At  Halifax,  the  fee  income  is  some  $5000  a  year  and  the 
government  makes  an  appropriation  of  $1200, — a  total  of  $6200.  The  faculty  ap- 
portions this  sum  as  follows :  three-fourths  of  the  fees  are  divided  among  the  teach- 
ers; one-fourth  of  the  fees  plus  the  government  subsidy  must  carry  all  other  expense, — 
heat,  light,  janitor  service,  laboratory  maintenance :  the  disgraceful  condition  of  the 
premises  follows  as  a  matter  of  course.  The  Hahnemann  of  Philadelphia,  with  esti- 
mated receipts  of  $18,500,  distributes  $11,000  among  teaching  practitioners  and 
spends  perhaps  $1500  on  equipment  and  $500  for  laboratory  material.  Advertising 
and  commencement  exercises — the  latter  only  another  form  of  advertising — often 
cost  these  institutions  more  than  their  laboratories.  One  large  eastern  institution 
expends  $4700  on  publicity,  as  against  $3500  on  its  laboratories;  another — a  New 
York  school,  this — $1500  on  publicity,  $1100  on  laboratories;  another,  $2100  on  ad- 
vertising, $1160  on  laboratories;  another — this  time  in  the  south — $1000  on  adver- 
tising, $500  on  laboratories,  "including  repairs."1 

The  conclusion,  then,  is  irresistible  that  these  schools,  far  from  being  the  benevo- 
lent enterprises  that  they  are  alleged  to  be,  still  "pay,1"  both  directly  and  indirectly; 
nor  can  a  genuine  altruistic  motive  be  made  out  for  any  medical  school  which  does 
not  consistently  devote  its  entire  income  to  providing  decent  facilities  and  adequate 
instruction  in  the  laboratories,  where  the  teachers,  if  competent,  must  rely  wholly  on 
their  salaries.  Clinical  teachers  ought  undoubtedly  be  paid,  but  not  out  of  fees 
at  the  expense  of  laboratories  and  laboratory  men.  Institutions  that  supplement  their 
fee  income  out  of  special  endowments  or  out  of  their  general  funds  very  properly  go 
ahead  to  pay  their  clinical  teachers;  otherwise  the  practitioner  teacher  must  be  subor- 
dinated. That  these  schools  have  been  persistently  used  for  pecuniary  advantage  is 
clear  when  an  inventory  of  their  belongings  is  contrasted  with  the  annual  income 
that  has  in  some  cases  been  earned  for  many  years.  They  have  little  or  nothing  to 
show  in  the  way  of  equipment.  The  medical  department  of  the  University  of  Arkan- 
sas is  thirty  years  old;  its  annual  receipts  are  now  $14,100;2  except  fora  small  recent 
investment,  it  is  practically  bare.  The  medical  department  of  Georgetown  Univer- 
sity (Washington,  D.C.)  has  been  in  operation  almost  sixty  years;  its  annual  income 
is  now  estimated  at  $11,000.  Its  plant  can  represent  only  a  small  fraction  of  its  re- 
ceipts during  its  lifetime.  The  Medical  College  of  Georgia  is  seventy  years  old ;  it  has 
accumulated  no  plant  worthy  the  name.  The  medical  department  of  the  University 
of  Oregon,  started  in  1887,  with  a  present  fee  income  of  $8000  and  state  aid  of  $1000 
a  year,  has  only  one  small  laboratory  that  represents  any  investment  at  all.  The 
medical  department  of  the  University  of  Chattanooga — twenty-one  years  old — with 
an  income  now  of  $4290,  of  which  the  dean  draws  $1800,  would  not,  if  sold  under 

1  Additional  examples  to  prove  that  the  schools  are  operated  for  the  profit  of  their  faculties  may  be 
given  if  necessary  :  University  of  Alabama,  fee  income  $19,788,  salaries  $14,000;  University  of  Ver- 
mont, fee  income,  $22,730,  salaries  and  dividends,  $17,489  (laboratories,  supplies,  etc.,  $1941,  publicity. 

$1289). 

2  Estimated. 


140  MEDICAL  EDUCATION 

the  hammer,  bring  $500.  The  St.  Louis  College  of  Physicians  and  Surgeons,  with  an 
estimated  income  of  SI 6,035,  cannot  afford  the  simplest  equipment  for  its  squalid 
dispensary  and  its  hopeless  laboratories.  The  osteopaths  bid  fair  to  repeat  the  worst 
offenses  of  the  medical  practitioners :  their  schools  are  fairly  booming.  The  receipts 
of  the  Kirksville  institution  probably  reach  $89,600  a  year.  The  instruction  fur- 
nished is  exceedingly  cheap  in  quality.  All  in  all,  there  are  annually  paid  in  the 
United  States  and  Canada  about  $3,000,000  in  medical  student  fees.  An  equal  sum 
has  been  paid  annually  for  years.  It  is  obvious  that  only  a  small  part  of  the  total 
fee  income  of  our  medical  schools  has  been  devoted  to  upbuilding  and  equipping  the 
schools,  though  just  the  reverse  is  pretended.  Undoubtedly,  the  disfavor  with  which 
educational  benefactors  have  regarded  medical  education  is  justified  by  the  merce- 
nary record  reflected  in  these  figures.  But  it  is  highly  important  that  henceforth 
distinctions  be  made. 

There  are  in  the  United  States  and  Canada  56 l  schools  whose  total  annual  avail- 
able resources  are  below  $10,000  each, — so  small  a  sum  that  the  endeavor  to  do  any- 
thing substantial  with  it  is  of  course  absurdly  futile;  a  fact  which  is  usually  made 
an  excuse  for  doing  nothing  at  all,  not  even  washing  the  windows,  sweeping  the  floor, 
or  providing  a  disinfectant  for  the  dissecting-room.  There  is  not  a  shred  of  justifica- 
tion for  their  continuance:  for  even  if  there  were  need  of  several  thousand  doctors 
annually,  the  wretched  contribution  made  by  these  poverty-stricken  schools  could 
well  be  spared.  Among  them  may  be  mentioned  the  California  Eclectic  (Los  Angeles), 
estimated  income  $1060;  Pulte  Medical  College  (Cincinnati), estimated  income  $1325 ; 
Toledo  Medical  College,  with  $3240 ;  Willamette  University,  with  $3580;  and  South- 
western Homeopathic  College,  with  $1100. 

Responsibility  for  the  conditions  described  does  not  rest  on  medical  men  alone; 
colleges  and  universities  have  not  infrequently  become  accessory  after  the  fact.  We 
have  repeatedly  urged  that  the  proper  place  for  a  medical  school  is  within  a  univer- 
sity; but  there  is  no  saving  grace  in  the  mere  name.  Three  services  may  be  specified 
as  comprised  in  the  duty  of  a  university  which  makes  itself  responsible  for  a  me- 
dical school :  the  definition  and  enforcement  of  entrance  standards,  the  upholding 
of  scientific  ideals,  and  responsibility  for  adequate  support.  Wehave  mentioned  univer- 
sities that  fail  in  the  first  or  the  second  or  in  both;  and  as  a  rule  these  are  the  in- 
stitutions that  fail  likewise  in  the  third.  Of  the  155  medical  schools  of  the  continent, 
82  are  university  departments,  actual  or  so-called.  With  few  exceptions  the  connec- 
tion of  these  universities  with  medical  education  began  at  a  time  when  no  one  took 
obligations  in  the  matter  seriously.  Some  of  those  that  entered  the  field  thus  lightly 
have  made  amends.  Others,  awakening  late  to  a  sense  of  their  obligations,  are  con- 
fronted by  an  apparently  hopeless  situation.  Their  total  annual  income  would  not 
alone  suffice  for  a  good  medical  school, — and  it  must  carry  the  burden  of  the  entire 

1  There  are  thirteen  more  whose  fee  income  is  likewise  below  §10,000  apiece,  but  they  are  university 
departments  whose  budgets,  greatly  in  excess  of  fees,  are  carried  by  the  respective  universities. 


FINANCIAL  ASPECTS  141 

institution.  Their  medical  departments  will,  unless  discontinued,  prove  sources  of 
weakness  and  reproach,  until  their  income  is  augmented  far  beyond  their  immediate 
expectations.  As  a  matter  of  fact,  few  university  administrators  yet  grasp  clearly  the 
fundamental  principles  of  modern  medical  education.  Twenty-seven  colleges  and 
universities  of  the  United  States  and  Canada  have  nominal  or  affiliated  medical  de- 
partments which  they  do  not  control  and  which  they  do  not  help  to  support.  The 
state  universities  of  Arkansas,  Georgia,  Illinois,  and  Oregon  are  in  this  position. 
Among  endowed  institutions  that  lend  their  names  to  proprietary  medical  schools, 
for  which  they  can  hope  to  do  nothing  and  which  they  cannot  possibly  control  as 
long  as  they  do  nothing,  are  the  University  of  Denver,  Washburn  College,  Cotner 
University,  Epworth,  Baylor,  Western,  and  Dalhousie  Universities.  Some  of  these 
institutions  are  very  poor.  Among  those  that  are  capable  of  leading  respectable 
lives  as  colleges,  but  are  little  less  than  absurd  as  universities,  may  be  mentioned 
Union  University,  in  New  York  state,  which  is  the  appellation  given  to  the  super- 
ficial combination  of  Union  College  and  the  Albany  Law  and  Medical  Schools.  The 
chancellor  of  the  University  of  Denver, — aMethodist  institution,  —  affiliated  with  the 
Denver  and  Gross  Medical  College,  finds  a  strange  reason  for  self-congratulation  in 
the  connection.  "The  University  of  Denver,"  he  says  in  a  recent  report,  "has  always 
had  a  form  of  organization  that  is  peculiar  to  itself.  From  the  beginning  the  profes- 
sional schools  have  had  autonomous  life.  The  church  has  never  expended  one  penny 
for  equipment  or  for  buildings  or  for  maintenance  of  the  professional  schools. ...  It 
has  made  a  notable  extension  of  its  influence  in  very  many  ways  through  the  profes- 
sional schools  of  the  university  without  the  expenditure  of  a  penny  for  any  purpose 
whatsoever."  A  highly  diverting  illustration  of  the  seriousness  with  which  these  ties 
are  regarded  has  been  recently  furnished  at  Los  Angeles ;  there  a  local  school,  affili- 
ated with  the  University  of  Southern  California,  saw  a  chance  of  improving  its  lot 
by  contracting  an  alliance  with  the  University  of  California.  A  divorce  was  speedily 
agreed  on,  and  the  University  of  California,  protected  by  contract,  however,  against 
any  expenditure  for  two  years,  promptly  became  sponsor  for  a  second  clinical  school. 
The  University  of  Southern  California,  however,  enjoyed  only  a  brief  widowhood.  Into 
the  vacant  place,  the  Los  Angeles  College  of  Physicians  and  Surgeons  promptly 
stepped.  The  University  of  Southern  California  was  thus  again  made  whole  by  the 
addition  of  a  medical  department  which,  enjoying  an  estimated  total  fee  income  of 
$4075,  will  ask  nothing  for  support  and  still  less  for  supervision. 

The  strength  of  the  argument  advanced  in  this  chapter  is  not  dependent  on  the 
absolute  accuracy  of  the  figures  cited.  Actual  income  may  vary  from  our  estimates 
a  few  thousand  dollars  up  or  down;  we  may  have  failed  to  consider  this  offset  or 
that.  It  has  been,  as  a  matter  of  fact,  utterly  impossible  to  get  figures  that  represent 
exactly  the  same  items  in  all,  or  even  in  many,  institutions.  An  improvement  in 
institutional  book-keeping  would  have  to  be  effected  in  order  to  make  accurate  com- 
parison possible.  None  the  less,  the  picture  is  on  the  whole  fair  and  reliable.  Medi- 


142  MEDICAL  EDUCATION 

cine  is  expensive  to  teach.  It  can  in  no  event  be  taught  out  of  fees.  Reputable  insti- 
tutions with  no  other  outlook  should  combine  with  better  favored  schools  or  stop 
outright.  Legal  enactment  should  terminate  the  career  of  the  others.  Abundant  bene- 
faction should  strengthen  up  to  our  need  the  relatively  small  number  of  schools  re- 
quired to  deal  effectively  with  the  subject.  No  greater  error  can  be  made  than  to  sup- 
pose that  endowment  and  university  ideals  are  necessary  only  to  medical  schools 
with  high  entrance  standards.  Vanderbilt  and  Tulane,  trying  to  make  intelligent 
physicians  out  of  high  school  boys  in  the  south,  need  the  same  means  and  ideals  as 
Harvard  and  Johns  Hopkins,  working  with  college  material  in  another  section.  In- 
deed, the  more  defective  the  material  or  the  more  unfavorable  the  environment,  the 
greater  must  be  the  resources  and  the  higher  must  be  the  purposes  of  those  who  have 
undertaken  to  look  after  this  vital  social  function. 


CHAPTER  IX 

RECONSTRUCTION 

THE  necessity  of  a  reconstruction  that  will  at  once  reduce  the  number  and  improve 
the  output  of  medical  schools  may  now  be  taken  as  demonstrated.  A  considerable 
sloughing  off  has  already  occurred.  It  would  have  gone  further  but  for  the  action  of 
colleges  and  universities  which  have  by  affiliation  obstructed  nature's  own  effort  at 
readjustment.  Affiliation  is  now  in  the  air.  Medical  schools  that  have  either  ceased 
to  prosper,  or  that  have  become  sensitive  to  the  imputation  of  proprietary  status  or 
commercial  motive,  seek  to  secure  their  future  or  to  escape  their  past  by  contracting 
an  academic  alliance.  The  present  chapter  undertakes  to  work  out  a  schematic  re- 
construction which  may  suggest  a  feasible  course  for  the  future.  It  is  not  supposed 
that  violent  measures  will  at  once  be  taken  to  reconstitute  the  situation  on  the  basis 
here  worked  out.  A  solution  so  entirely  suggested  by  impersonal  considerations  may 
indeed  never  be  reached.  But  legislators  and  educators  alike  may  be  assisted  by  a 
theoretical  solution  to  which,  as  specific  problems  arise,  they  may  refer. 

This  solution  deals  only  with  the  present  and  the  near  future, — a  generation,  at 
most.  In  the  course  of  the  next  thirty  years  needs  will  develop  of  which  we  here  take 
no  account.  As  we  cannot  foretell  them,  we  shall  not  endeavor  to  meet  them.  Certain 
it  is  that  they  will  be  most  effectively  handled  if  they  crop  up  freely  in  an  unen- 
cumbered field.  It  is  therefore  highly  undesirable  that  superfluous  schools  now  exist- 
ing should  be  perpetuated  in  order  that  a  subsequent  generation  may  find  a  means 
of  producing  its  doctors  provided  in  advance.  The  cost  of  prolonging  life  through 
this  intervening  period  will  be  worse  than  wasted;  and  an  adequate  provision  at 
that  moment  will  be  embarrassed  by  inheritance  and  tradition.  Let  the  new  founda- 
tions of  that  distant  epoch  enjoy  the  advantage  of  the  Johns  Hopkins,  starting  with- 
out handicap  at  the  level  of  the  best  knowledge  of  its  day. 

The  principles  upon  which  reconstruction  would  proceed  have  been  established  in 
the  course  of  this  report:  (1)  a  medical  school  is  properly  a  university  department; 
it  is  most  favorably  located  in  a  large  city,  where  the  problem  of  procuring  clinical 
material,  at  once  abundant  and  various,  practically  solves  itself.  Hence  those  univer- 
sities that  have  been  located  in  cities  can  most  advantageously  develop  medical 
schools.  (2)  Unfortunately,  however,  our  universities  have  not  always  been  so  placed. 
They  began  in  many  instances  as  colleges  or  something  less.  Here  a  supposed  solici- 
tude for  youth  suggested  an  out-of-the-way  location ;  elsewhere  political  bargaining 
brought  about  the  same  result.  The  state  universities  of  the  south  and  west,  most 
likely  to  enjoy  sufficient  incomes,  are  often  unfortunately  located:  witness  the  Univer- 
sity of  Alabama  at  Tuscaloosa,  of  Georgia  at  Athens,  of  Mississippi  at  Oxford,  of 
Missouri  at  Columbia,  of  Arkansas  at  Fayetteville,  of  Kansas  at  Lawrence,  of  South 
Dakota  at  Vermilion;  and  that  experience  has  taught  us  nothing  is  proved  by  the 


144  MEDICAL  EDUCATION 

recent  location  of  the  State  University  of  Oklahoma  at  Norman.  Some  of  these  insti- 
tutions are  freed  from  the  necessity  of  undertaking  to  teach  medicine  by  an  endowed 
institution  better  situated;  in  other  sections  the  only  universities  fitted  by  their  large 
support  and  their  assured  scientific  ideals  to  maintain  schools  of  medicine  are  handi- 
capped by  inferiority  of  location.  We  are  not  thereby  justified  in  surrendering  the 
university  principle.  Experience,  our  own  or  that  of  Germany,  proves,  as  we  have 
already  pointed  out,  that  the  difficulty  is  not  insuperable.  At  relatively  greater  ex- 
pense, it  is  still  feasible  to  develop  a  medical  school  in  such  an  environment :  there  is 
no  magnet  like  reputation ;  nothing  travels  faster  than  the  fame  of  a  great  healer;  dis- 
tance is  an  obstacle  readily  overcome  by  those  who  seek  health.  The  poor  as  well  as 
the  rich  find  their  way  to  shrines  and  healing  springs.  The  faculty  of  medicine  in 
these  schools  may  even  turn  the  defect  of  situation  to  good  account;  for,  freed  from 
distraction,  the  medical  schools  at  Iowa  City  and  Ann  Arbor  may  the  more  readily 
cultivate  clinical  science.  An  alternative  may  indeed  be  tried  in  the  shape  of  a  remote 
department.  The  problem  in  that  case  is  to  make  university  control  real,  to  impregnate 
the  distant  school  with  genuine  university  spirit.  The  difficulty  of  the  task  may  well 
deter  those  whose  resources  are  scanty  or  who  are  under  no  necessity  of  engaging 
in  medical  teaching.  As  we  need  many  universities  and  but  few  medical  schools,  a 
long-distance  connection  is  justified  only  where  there  is  no  local  university  qualified 
to  assume  responsibility.  A  third  solution — division — may,  if  the  position  taken 
in  previous  chapters  is  sound,  be  disregarded  in  the  final  disposition.1 

(3)  We  shall  assign  only  one  school  to  a  single  town.  As  a  matter  of  fact,  no 
American  city  now  contains  more  than  one  well  supported  university,2 — and  if  we 
find  it  unnecessary  or  impolitic  to  duplicate  local  university  plants,  it  is  still  less  neces- 
sary to  duplicate  medical  schools.  The  needless  expense,  the  inevitable  shrinkage  of 
the  student  body,  the  difficulty  of  recruiting  more  than  one  faculty,  the  disturbance 
due  to  competition  for  hospital  services,  argue  against  local  duplication.  It  is  some- 
times contended  that  competition  is  stimulating:  Tufts  claims  to  have  waked  up 
Harvard;  the  second  Little  Rock  school  did  undoubtedly  move  the  first  to  spend 
several  hundred  dollars  on  desks  and  apparatus.  But  competition  may  also  be  de- 
moralizing; the  necessity  of  finding  students  constitutes  medical  schools  which  ought 
to  elevate  standards  the  main  obstacles  to  their  elevation :  witness  the  attitude  of 
several  institutions  in  Boston,  New  York,  Philadelphia,  Baltimore,  and  Chicago. 
Moreover,  local  competition  is  a  stimulus  far  inferior  to  the  general  scientific  compe- 
tition to  which  all  well  equipped,  well  conducted,  and  rightly  inspired  university 
departments  throughout  the  civilized  world  are  parties.  The  English  have  experi- 
mented with  both  forms, — a  single  school  in  the  large  provincial  towns,  a  dozen 
or  more  in  London, — and  their  experience  inclines  them  to  reduce  as  far  as  possible 

1  We  shall  omit  the  half-school  because  it  may  be  considered  to  divide  with  the  whole  school  the  work 
of  the  first  two  years ;  it  does  not  greatly  affect  the  clinical  output,  with  which  this  chapter  is  mainly 
concerned. 

2  Chicago  is  almost  an  exception,  as  Northwestern  University  is  situated  at  Evanston,  a  suburb. 


RECONSTRUCTION  145 

the  number  of  the  London  schools.  Amalgamation  has  already  taken  place  in  cer- 
tain American  towns :  the  several  schools  of  Cincinnati,  of  Indianapolis,  and  of  Louis- 
ville have  all  recently  "merged."  This  step  is  easy  enough  in  towns  where  there  is 
either  no  university  or  only  one  university.  Where  there  are  several,  as  in  Chicago, 
Boston,  and  New  York,  the  problem  is  more  difficult.  Approached  in  a  broad  spirit 
it  may,  however,  prove  not  insoluble;  cooperation  may  be  arranged  where  several 
institutions  all  possess  substantial  resources;  universities  of  limited  means  can  retire 
without  loss  of  prestige, —  on  the  contrary,  the  respect  in  which  they  are  held  must 
be  heightened  by  any  action  dictated  by  conscientious  refusal  to  continue  a  work 
that  they  are  in  no  position  to  do  well. 

(4)  A  reconstruction  of  medical  education  cannot  ignore  the  patent  fact  that  stu- 
dents tend  to  study  medicine  in  their  own  states,  certainly  in  their  own  sections.  In 
general,  therefore,  arrangements  ought  to  be  made,  as  far  as  conditions  heretofore 
mentioned  permit,  to  provide  the  requisite  facilities  within  each  of  the  characteris- 
tic state  groups.  There  is  the  added  advantage  that  local  conditions  are  thus  heeded 
and  that  the  general  profession  is  at  a  variety  of  points  penetrated  by  educative  in- 
fluences. New  Orleans,  for  example,  would  cultivate  tropical  medicine ;  Pittsburgh, 
the  occupational  diseases  common  in  its  environment.  In  respect  to  output,  we  may 
once  more  fairly  take  existing  conditions  into  account.  We  are  not  called  on  to 
provide  schools  enough  to  keep  up  the  present  ratio.  As  we  should  in  any  case 
hardly  be  embarrassed  for  almost  a  generation  in  the  matter  of  supply,  we  shall  do 
well  to  produce  no  doctors  who  do  not  represent  an  improvement  upon  the  present 
average. 

The  principles  above  stated  have  been  entirely  disregarded  in  America.  Medical 
schools  have  been  established  regardless  of  need,  regardless  of  the  proximity  of  com- 
petent universities,  regardless  of  favoring  local  conditions.  An  expression  of  surprise 
at  finding  an  irrelevant  and  superfluous  school  usually  elicits  the  reply  that  the 
town,  being  a  "gateway  "  or  a  "  center,"  must  of  course  harbor  a  "  medical  college." 
It  is  not  always  easy  to  distinguish  "gateway""  and  "center:"  a  center  appears  to  be 
a  town  possessing,  or  within  easy  reach  of,  say  50,000  persons;  a  gateway  is  a  town 
with  at  least  two  railway  stations.  The  same  place  may  be  both, — in  which  event 
the  argument  is  presumably  irrefragable.  Augusta,  Georgia,  Charlotte,  North  Caro- 
lina, and  Topeka,  Kansas,  are  "centers,"  and  as  such  are  logical  abodes  of  medical  in- 
struction. Little  Rock,  St.  Joseph,  Memphis,  Toledo,  Buffalo,  are  "gateways."  The  ar- 
gument, so  dear  to  local  pride,  can  best  be  refuted  by  being  pursued  to  its  logical 
conclusion.  For  there  are  still  forty-eight  towns  in  the  United  States  with  over 
50,000  population  each,  and  no  medical  schools :  we  are  threatened  with  forty-eight 
new  schools  at  once,  if  the  contention  is  correct.  The  truth  is  that  the  fundamental, 
though  of  course  not  sole,  consideration  is  the  university,  provided  its  resources  are 
adequate;  and  we  have  fortunately  enough  strong  universities,  properly  distributed, 
to  satisfy  every  present  need  without  serious  sacrifice  of  sound  principle.  The  Ger- 


146  MEDICAL  EDUCATION 

man  Empire  contains  eighty-four  cities  whose  population  exceeds  50,000  each.  Of  its 
twenty-two  medical  schools,  only  eleven  are  to  be  found  in  them :  that  is,  it  possesses 
seventy-three  gateways  and  centers  without  universities  or  medical  schools.  The  re- 
maining eleven  schools  are  located  in  towns  of  less  than  50,000  inhabitants,  a  uni- 
versity town  of  30,000  being  a  fitter  abode  for  medical  study  than  a  non-university 
town  of  half  a  million,  in  the  judgment  of  those  who  have  best  succeeded  with  it. 

That  the  existing  system  came  about  without  reference  to  what  the  country 
needed  or  what  was  best  for  it  may  be  easily  demonstrated.  Between  1904  and  1909 
the  country  gained  certainly  upwards  of  5,000,000  in  population;  during  the  same 
period  the  number  of  medical  students  actually  decreased  from  28,142  to  22,145,  i.e., 
over  20  per  cent.  The  average  annual  production  of  doctors  from  1900  to  1909  was 
5222;  but  last  June  the  number  dropped  to  4442.  Finally,  the  total  number  of 
medical  colleges  which  reached  its  maximum — 1661 —  in  1904  has  in  the  five  years 
since  decreased  about  10  per  cent.  Our  problem  is  to  calculate  how  far  tendencies 
already  observable  may  be  carried  without  harm. 

We  have  calculated  that  the  south  requires  for  the  next  generation  490  new  doc- 
tors annually,  the  rest  of  the  country,  1500.  We  must  then  provide  machinery  for  the 
training  of  about  2000  graduates  in  medicine  yearly.  Reckoning  fatalities  of  all  kinds 
at  ten  per  cent  per  annum,  graduating  classes  of  2000  imply  approximately  junior 
classes  of  2200,  sophomore  classes  of  2440,  freshman  classes  aggregating  2700, — 
something  over  9000  students  of  medicine.  Thirty  medical  schools,  with  an  average 
enrolment  of  300  and  average  graduation  classes  of  less  than  70,  will  be  easily  equal 
to  the  task.  As  many  of  these  could  double  both  enrolment  and  output  without 
danger,  a  provision  planned  to  meet  present  needs  is  equally  sufficient  for  our  growth 
for  years  to  come.  It  will  be  time  to  devise  more  schools  when  the  productive  limit 
of  those  now  suggested  shall  come  in  sight. 

For  the  purpose  here  in  mind,  the  country  may  be  conceived  as  divided  into  sev- 
eral sections,  within  each  of  which,  with  due  regard  to  what  it  now  contains,  medical 
schools  enough  to  satisfy  its  needs  must  be  provided.8  Pending  the  fuller  develop- 
ment of  the  states  west  of  the  Mississippi,  the  section  east  will  have  to  relieve  them 
of  part  of  their  responsibility.  The  provisional  nature  of  our  suggestions  is  thus 
obvious;  for  as  the  west  increases  in  population,  as  its  universities  grow  in  number 
and  strength,  the  balance  will  right  itself:  additional  schools  will  be  created  in  the 
west  and  south  rather  than  in  the  north  and  east.  It  would  of  course  be  unfortunate 
to  over-emphasize  the  importance  of  state  lines.  We  shall  do  well  to  take  advantage 
of  every  unmistakably  favorable  opportunity  so  long  as  we  keep  within  the  public 
need;  and  to  encourage  the  freest  possible  circulation  of  students  throughout  the 
entire  country. 

1  Not  including  osteopathic  schools. 

a  This  chapter  now  recapitulates  and  summarizes  the  more  detailed  accounts  contained  in  Part  II,  in 
which  the  schools  of  each  state  are  described  and  the  general  state  situation  discussed. 


RECONSTRUCTION  147 

(1)  New  England  represents  a  fairly  homogeneous  region,  comprising  six  states, 
the  population  of  which  is  increasingly  urban.  Its  population  increased,  1908-9, 
somewhat  less  than  75,000,  requiring,  on  the  basis  of  one  doctor  to  every  increase 
of  1500  in  population,  50  new  doctors.  About  150  physicians  died.  Seventy-five 
men  would  replace  one-half  of  these.  In  all,  125  new  doctors  would  be  needed. 
To  produce  this  number  two  schools,  one  of  moderate  size  and  one  smaller,  readily 
suffice.  Fortunately  they  can  be  developed  without  sacrificing  any  of  our  criteria. 
The  medical  schools  of  Harvard  and  Yale  are  university  departments,  situated  in 
the  midst  of  ample  clinical  material,  with  considerable  financial  backing  now  and 
every  prospect  of  more.  It  is  unwise  to  divide  the  Boston  field;  it  is  unnecessary  to  pro- 
long the  life  of  the  clinical  departments  of  Dartmouth,  Bowdoin,  and  Vermont.  They 
are  not  likely  soon  to  possess  the  financial  resources  needed  to  develop  adequate  cli- 
nics in  their  present  location ;  and  the  time  has  passed  when  even  excellent  didactic 
instruction  can  be  regarded  as  compensating  for  defective  opportunities  in  obstetrics, 
contagious  diseases,  and  general  medicine.  The  historic  position  of  the  schools  in 
question  counts  little  as  against  changed  ideals.  Dartmouth  and  Vermont  can,  how- 
ever, offer  the  work  of  the  first  two  years  with  the  clinical  coloring  made  feasible 
by  the  proximity  of  a  hospital,  as  is  the  case  with  the  University  of  Missouri  at  Co- 
lumbia; with  that  they  ought  to  be  content  for  the  time  being. 

(2)  The  middle  Atlantic  states  comprise  for  our  purpose  New  York,  New  Jersey, 
Pennsylvania,  Delaware,  Maryland,  and  the  District  of  Columbia.  Their  population 
grows  at  the  rate  of  300,000  annually,  for  whom  200  doctors  can  care;  230  more  would 
fill  one-half  the  vacancies  arising  through  death :  a  total  of  430  needed.  Available 
universities  are   situated  in  New  York  city,  Syracuse,  Philadelphia,  Pittsburgh, 
Baltimore.  The  situation  is  in  every  respect  ideal;  the  universities  located  at  New 
York,  Philadelphia,  and  Baltimore  are  strong  and  prosperous;  those  of  Syracuse 
and  Pittsburgh,  though  less  developed,  give  good  promise.  Without  sacrifice  of  a 
single  detail,  these  five  university  towns  can  not  only  support  medical  schools  for 
the  section,  but  also  to  no  small  extent  relieve  less  favored  spots.  The  schools  of 
Albany,  Buffalo,  Brooklyn,  Washington,1  would,  on  this  plan,  disappear, — certainly 
until  academic  institutions  of  proper  caliber  had  been  developed.  Whether  even  in 
the  event  of  their  creation  they  should  for  some  years  endeavor  to  cultivate  medicine 
is  quite  doubtful.  Appreciation  of  what  is  involved  in  the  undertaking  might  well 
give  them  pause.  Meanwhile,  within  the  university  towns  already  named  there  would 
be  much  to  do :  better  state  laws  are  needed  in  order  to  exterminate  the  worst  schools ; 
merger  or  liquidation  must  bring  together  many  of  those  that  still  survive.  The 
section  under  consideration  ought  indeed  to  lead  the  Union;  but  the  independent 
schools  of  New  York  and  Pennsylvania  are  powerful  enough  to  prove  a  stubborn 
obstacle  to  any  progressive  movement,  however  clearly  in  the  public  interest. 

1  Except  Howard  University  which,  patronized  by  the  government,  is  admirably  located  for  the 
medical  education  of  the  negro. 


148  MEDICAL  EDUCATION 

(3)  Greater  unevenness  must  be  tolerated  in  the  south;1  proprietary  schools  or  nom- 
inal university  departments  will  doubtless  survive  longer  there  than  in  other  parts  of 
the  country  because  of  the  financial  weakness  of  both  endowed  and  tax-supported  in- 
stitutions. All  the  more  important,  therefore,  for  universities  to  deal  with  the  subject 
in  a  large  spirit,  avoiding  both  overlapping  and  duplication.  An  institution  may  well 
be  glad  to  be  absolved  from  responsibilities  that  some  other  is  better  fitted  to  meet. 
Tulane  and  Vanderbilt,  for  example,  are  excellently  situated  in  respect  to  medical 
education ;  the  former  has  already  a  considerable  endowment  applicable  to  medicine. 
The  state  universities  of  Louisiana  and  Tennessee  may  therefore  resign  medicine  to 
these  endowed  institutions,  grateful  for  the  opportunity  to  cultivate  other  fields. 
Every  added  superfluous  school  weakens  the  whole  by  wasting  money  and  scattering 
the  eligible  student  body.  None  of  the  southern  state  universities,  indeed,  is  wisely 
placed :  Texas  has  no  alternative  but  a  remote  department,  such  as  it  now  supports 
at  Galveston;  Georgia  will  one  day  develop  a  university  medical  school  at  Atlanta; 
Alabama,  at  Birmingham, — the  university  being  close  by,  at  Tuscaloosa.  The  Uni- 
versity of  Virginia  is  repeating  Ann  Arbor  at  Charlottesville;  whether  it  would  do 
better  to  operate  a  remote  department  at  Richmond  or  Norfolk,  the  future  will  deter- 
mine. Six  schools  are  thus  provided:2  they  are  sufficient  to  the  needs  of  the  section 
just  now.  The  resources  available  even  for  their  support  are  as  yet  painfully  inade- 
quate: three  of  the  six  are  still  dependent  upon  fees  for  both  plant  and  maintenance. 
It  is  doubtful  whether  the  other  universities  of  the  south  should  generally  offer  even 
the  instruction  of  the  first  two  years.  The  scale  upon  which  these  two-year  depart- 
ments can  be  now  organized  by  them  is  below  the  minimum  of  continuous  efficiency; 
they  can  contribute  nothing  to  science,  and  their  quota  of  physicians  can  be  better 
trained  in  one  of  the  six  schools  suggested.  Concentration  in  the  interest  of  effective- 
ness, team  work  between  all  institutions  working  in  the  cause  of  southern  development, 
economy  as  a  means  of  improving  the  lot  of  the  teacher — these  measures,  advisable 
everywhere,  are  especially  urgent  in  the  south. 

(4)  In  the  north  central  tier — Ohio,  Indiana,  Michigan,  Wisconsin,  Illinois — 
population  increased  239,685  the  last  year:  160  doctors  would  care  for  the  increase; 
190  more  would  replace  one-half  of  those  that  died:  a  total  of  350.  Large  cities  with 
resident  universities  available  for  medical  education  are  Cincinnati,  Columbus,  Cleve- 
land, and  Chicago.  Ann  Arbor  has  demonstrated  the  ability  successfully  to  combat 
the  disadvantages  of  a  small  town.  The  University  of  Wisconsin  can  unquestionably 
do  the  same,  with  a  slighter  handicap,  at  Madison  whenever  it  chooses  to  complete 
its  work  there.  Indiana  University  has  undertaken  the  problem  of  a  distant  connec- 
tion at  Indianapolis.  Four  cities  thus  fulfil  all  our  criteria,  two  more  develop  the 
small  town  type,  one  more  is  an  experiment  with  the  remote  university  department. 

lTbe  south  includes  eleven  states,  riz.,  Virginia,  Kentucky,  North  Carolina,  South  Carolina,  Florida, 
Georgia,  Tennessee,  Mississippi,  Louisiana,  Arkansas,  Texas. 

*A  seventh,  Meharry,  at  Nashville,  must  be  included  for  the  medical  education  of  the  negro. 


RECONSTRUCTION  149 

Surely  the  territory  in  question  can  be  supplied  by  these  seven  medical  centers.  Chi- 
cago alone  is  likely  to  draw  a  considerable  number  of  students  from  a  wider  area.  It 
has  long  been  a  populous  medical  center.  Nevertheless  the  number  of  high-grade  stu- 
dents it  just  now  contains  is  not  large.  If  the  practice  of  medicine  in  this  area  rested 
on  a  two-year  college  basis,  as  it  well  might,  there  would  to-day  be  perhaps  600 
students  of  medicine  in  that  city.  Cooperative  effort  between  the  two  universities 
there  and  the  state  university  at  Urbana  would  readily  provide  for  them. 

(5)  The  middle  west  comprises  eight  states,  Minnesota,  Iowa,  Missouri,  Okla- 
homa, Kansas,  Nebraska,  South  Dakota,  North  Dakota,  with  a  gain  in  popula- 
tion last  year  of  216,036,  requiring  140  more  physicians,  plus  160  to  replace  half 
the  deaths :  a  total  of  300.  To  supply  them,  urban  universities  capable  of  conduct- 
ing medical  departments  of  proper  type  are  situated  in  Minneapolis  and  St.  Louis; 
and  both  deserve  strong,  well  supported  schools.  For  Minneapolis  must  largely  carry 
the  weight  of  the  Dakotas  and  Montana;  St.  Louis  must  assist  Texas  and  have  an 
eye  to  Arkansas,  Oklahoma,  and  the  southwest.  The  University  of  Nebraska,  now 
dispersing  its  energies  through  a  divided  school,  can  be  added  to  this  list;  for  it 
will  quite  certainly  either  concentrate  the  department  on  its  own  site  (Lincoln,  pop- 
ulation 48,232),  or  bring  the  two  pieces  together  at  Omaha,  only  an  hours  distance 
away.  The  University  of  Kansas  will  doubtless  combine  its  divided  department  at 
Kansas  City.  The  State  University  of  Iowa  emulates  Ann  Arbor  at  Iowa  City. 
These  five  schools  must  produce  297  doctors  annually.  Their  capacity  would  go 
much  farther.  Oklahoma1  and  the  Dakotas  might  well  for  a  time  postpone  the  entire 
question,  supporting  the  work  of  the  first  two  years,  which  they  have  already  under- 
taken, on  a  much  more  liberal  basis  than  they  have  yet  reached.  With  the  exception  of 
St.  Louis,  all  these  proposed  schools  belong  to  state  universities,  and  even  at  St. 
Louis  the  cooperation  of  the  state  university  may  prove  feasible.  A  close  relation 
may  thus  be  secured  between  agencies  concerned  with  public  health  and  those  devoted 
to  medical  education.  The  public  health  laboratory  may  become  virtually  part  of  the 
medical  school, — a  highly  stimulating  relation  for  both  parties.  The  school  will 
profit  by  contact  with  concrete  problems ;  the  public  health  laboratory  will  inevitably 
push  beyond  routine,  prosecuting  in  a  scientific  spirit  the  practical  tasks  referred  to 
it  from  all  portions  of  the  state.  The  direct  connection  of  the  state  with  a  medical 
school  that  it  wholly  or  even  partly  maintains  will  also  solve  the  vexed  question  of 
standards :  for  the  educational  standard  which  the  state  fixes  for  its  own  sons  will  be 
made  the  practice  standard  as  well.  Private  corporations,  whether  within  or  without  its 
borders,  will  no  longer  be  permitted  to  deluge  the  community  with  an  inferior  product. 

(6)  Seven  thinly  settled  and  on  the  whole  slowly  growing  states  and  territories 
form  the  farther  west:  New  Mexico,  Colorado,  Wyoming,  Montana,  Idaho,  Utah, 
Arizona.  Their  increase  in  population  was  last  year  about  45,000.  They  contain  now 

1  Should  it  be  possible  for  the  State  University  of  Oklahoma,  by  engaging  in  clinical  work  at  Okla- 
homa City,  to  get  and  to  retain  a  monopoly  of  the  field,  the  step  would  doubtless  be  advisable  even  now. 


150  MEDICAL  EDUCATION 

one  doctor  for  every  563  persons.  In  view  of  local  conditions,  let  us  reckon  one  addi- 
tional doctor  for  every  additional  750  persons :  60  will  be  required.  And,  further, 
let  us  make  up  the  death-roll  man  for  man:  60  more  would  be  needed — altogether 
120.  There  are  at  the  moment  in  this  region  only  two  available  sites,  Salt  Lake 
City  and  Denver.  At  the  former  the  University  of  Utah  is  situated ;  the  latter  could 
be  occupied  by  the  University  of  Colorado,  located  at  Boulder,  practically  a  suburb. 
The  outlying  portions  of  this  vast  territory  will  long  continue  to  procure  their  doc- 
tors by  immigration  or  by  sending  their  sons  to  Minneapolis,  Madison,  Ann  Arbor, 
Chicago,  or  St.  Louis. 

(7)  The  three  states  on  the  Pacific  coast,  California,  Oregon,  Washington,  are  some- 
what self-contained.  They  increased  last  year  by  53,454  persons,  requiring  36  more 
physicians;  50  more  would  repair  one-half  the  losses  by  death:  a  total  of  86.  Avail- 
able sites,  filling  the  essential  requirements,  are  Berkeley  and  Seattle.  The  former, 
with  the  adjoining  towns  of  Alameda  and  Oakland,  controls  a  population  of  250,000 
or  more;  the  medical  department  of  the  University  of  California  concentrated  there 
would  enjoy  ideal  conditions.  At  present  the  clinical  ends  of  two  divided  schools  share 
San  Francisco,  and  the  outlook  for  medical  education  of  high  quality  is  rendered  du- 
bious by  the  division.  With  unique  wisdom  the  University  of  Washington  and  the 
physicians  of  Seattle1  have  thus  far  refrained  from  starting  a  medical  school  in 
that  state.  They  have  held,  and  rightly,  that  in  the  present  highly  overcrowded  con- 
dition of  the  profession  on  the  coast,  there  is  no  need  for  an  additional  ordinary 
school ;  and  the  resources  of  the  university  are  not  yet  adequate  to  a  really  creditable 
establishment.  The  field  will  therefore  be  kept  clear  until  the  university  is  in  posi- 
tion to  occupy  it  to  advantage. 

(8)  In  Canada  the  existing  ratio  of  physicians  to  population  is  1 :1030.  The  esti- 
mated increase  of  population  last  year  was  239,516,  requiring  160  new  physicians; 
losses  by  death  are  estimated  at  90.  As  the  country  is  thinly  settled  and  doctors 
much  less  abundant  than  in  the  United  States,  let  us  suppose  these  replaced  man  for 
man :  250  more  doctors  would  be  annually  required.  The  task  of  supplying  them 
could  be  for  the  moment  safely  left  to  the  Universities  of  Toronto  and  Manitoba,  to 
McGill  and  to  Laval  at  Quebec.  Halifax,  Western  (London),  and  Laval  at  Montreal 
have  no  present  function.  At  some  future  time  doubtless  Dalhousie  University  at 
Halifax  will  need  to  create  a  medical  department.  The  future  of  Queen's  depends  on 
its  ability  to  develop  halfway  between  Toronto  and  Montreal,  despite  comparative 

1  Copy  of  Extract  of  Minute* 

Of  the  King  County  Medical  Society  (State  of  Washington),  June  20,  1904. 

Committee.  On  motion  a  committee  consisting  of  F.  H.  Coe,  P.  W.  Willis,  and  R.  W.  Schoenle  was 
appointed  to  draw  up  suitable  resolutions  regarding  the  establishment  of  any  medical  preparatory 
course  in  the  University  of  Washington,  condemning  the  same  and  directed  to  the  regents  of  the 
institution. 

Committee.  A  committee,  consisting  of  H.  M.  Read,  L.  R.  Dawson,  J.  E.  :Harris,  N.  D.  Pontius, 
C.  A.  Smith,  and  I.  A.  Parry,  was  also  appointed  with  directions  to  visit  Dr.  Kane  personally  and 
urge  the  importance  of  our  position  upon  the  same  subject. 


RECONSTRUCTION  151 

inaccessibility,  the  Ann  Arbor  type  of  school.  As  for  the  rest,  the  great  northwestern 
territory  will,  as  it  develops,  create  whatever  additional  facilities  it  may  require. 

In  so  far  as  the  United  States  is  concerned,  the  foregoing  sketch  calls  for  31  medi- 
cal schools1  with  a  present  annual  output  of  about  2000  physicians,  i.  e.,  an  average 
graduating  class  of  about  70  each.  They  are  capable  of  producing  3500.  All  are 
university  departments,  busy  in  advancing  knowledge  as  well  as  in  training  doc- 
tors. Nineteen  are  situated  in  large  cities  with  the  universities  of  which  they  are 
organic  parts;  four  are  in  small  towns  with  their  universities;  eight  are  located  in 
large  towns  always  close  by  the  parent  institutions.  Divided  and  far  distant  depart- 
ments are  altogether  avoided. 

Twenty  states8  are  left  without  a  complete  school.  Most  of  these  are  unlikely  to 
be  favorably  circumstanced  for  the  next  half  century,  so  far  as  we  can  now  judge. 
Several  may,  however,  find  the  undertaking  feasible  within  a  decade  or  two.  The 
University  of  Arkansas  might  be  moved  from  Fayetteville  to  Little  Rock ;  Oklahoma, 
if  its  rapid  growth  is  maintained,  may  from  Norman  govern  a  medical  school  at 
Oklahoma  City;  Oregon  may  take  full  responsibility  for  Portland.  Unfortunately, 
of  the  three  additional  schools  thus  created,  only  one,  that  at  Little  Rock,  would 
represent  conditions  at  their  best.  There  is  therefore  no  reason  to  hasten  the  others; 
for  their  problem  may,  if  left  open,  be  more  advantageously  solved. 

To  bring  about  the  proposed  reconstruction,  some  120  schools  have  been  apparently 
wiped  off  the  map.  As  a  matter  of  fact,  our  procedure  is  far  less  radical  than  would 
thus  appear.  Of  the  120  schools  that  disappear,  37  are  already  negligible,  for  they  con- 
tain less  than  50  students  apiece;  13  more  contain  between  50  and  75  students  each, 
and  16  more  between  75  and  100.  That  is,  of  the  120  schools,  66  are  so  small  that 
their  student  bodies  can,  in  so  far  as  they  are  worthy,  be  swept  into  strong  institu- 
tions without  seriously  stretching  their  present  enrolment.  Of  the  30  institutions 
that  remain,  several  will  survive  through  merger.  For  example,  the  Cleveland  College 
of  Physicians  and  Surgeons  could  be  consolidated  with  Western  Reserve;  the  amal- 
gamation of  Jefferson  Medical  College  and  the  University  of  Pennsylvania  would  make 
one  fair-sized  school  on  an  enforced  two-year  college  standard;  Tufts  and  Harvard, 
Vanderbilt  and  the  University  of  Tennessee,  Creighton  and  the  University  of  Ne- 
braska, would,  if  joined,  form  institutions  of  moderate  size,  capable  of  considerable 
expansion  before  reaching  the  limit  of  efficiency. 

In  order  that  these  mergers  may  be  effective,  not  only  institutional,  but  personal 
ambition  must  be  sacrificed.  It  is  an  advantage  when  two  schools  come  together; 
but  the  advantage  is  gravely  qualified  if  the  new  faculty  is  the  arithmetical  sum  of 
both  former  faculties.  The  mergers  at  Cincinnati,  Indianapolis,  Louisville,  Nashville, 

1  The  accompanying  maps  contrast  the  existing  with  the  suggested  number  and  distribution.  Meharry 
and  Howard  are  included. 

2  They  are  Maine,  New  Hampshire,  Vermont,  West  Virginia,  North  Carolina,  South  Carolina,  Florida, 
Mississippi,  Kentucky,  Arkansas,  Oklahoma,  North  Dakota,  South  Dakota,  Montana,  Wyoming, 
Idaho,  New  Mexico,  Arizona,  Nevada,  Oregon.  One  school  will  not  long  content  the  state  of  Texas. 


154  MEDICAL  EDUCATION 

have  been  arranged  in  this  way.  The  fundamental  principles  of  faculty  organization 
are  thus  sacrificed.  Unless  combination  is  to  destroy  organization,  titles  must  be 
shaved  when  schools  unite.  There  must  be  one  professor  of  medicine,  one  professor 
of  surgery ,  etc.,  to  whom  others  are  properly  subordinated.  What  with  superabundant 
professorial  appointments,  due  now  to  desire  to  annex  another  hospital,  and  again 
to  annexation  of  another  school,  faculties  have  become  unmanageably  large,  viewed 
either  as  teaching,  research,  or  administrative  bodies. 

Reduction  of  our  155  medical  schools  to  31  would  deprive  of  a  medical  school 
no  section  that  is  now  capable  of  maintaining  one.  It  would  threaten  no  scarcity  of 
physicians  until  the  country's  development  actually  required  more  than  3500  physi- 
cians annually,  that  is  to  say,  for  a  generation  or  two,  at  least.  Meanwhile,  the  out- 
line proposed  involves  no  artificial  standardization:  it  concedes  a  different  standard 
to  the  south  as  long  as  local  needs  require;  it  concedes  the  small  town  university 
type  where  it  is  clearly  of  advantage  to  adhere  to  it;  it  varies  the  general  ratio  in 
thinly  settled  regions;  and,  finally,  it  provides  a  system  capable  without  overstraining 
of  producing  twice  as  many  doctors  as  we  suppose  the  country  now  to  need.  In  other 
words,  we  may  be  wholly  mistaken  in  our  figures  without  in  the  least  impairing  the 
feasibility  of  the  kind  of  renovation  that  has  been  outlined ;  and  every  institution 
arranged  for  can  be  expected  to  make  some  useful  contribution  to  knowledge  and 
progress. 

The  right  of  the  state  to  deal  with  the  entire  subject  in  its  own  interest  can  as- 
suredly not  be  gainsaid.  The  physician  is  a  social  instrument.  If  there  were  no  disease, 
there  would  be  no  doctors.  And  as  disease  has  consequences  that  immediately  go 
beyond  the  individual  specifically  affected,  society  is  bound  to  protect  itself  against 
unnecessary  spread  of  loss  or  danger.  It  matters  not  that  the  making  of  doctors 
has  been  to  some  extent  left  to  private  institutions.  The  state  already  makes  certain 
regulations;  it  can  by  the  same  right  make  others.  Practically  the  medical  school  is  a 
public  service  corporation.  It  is  chartered  by  the  state;  it  utilizes  public  hospitals  on 
the  ground  of  the  social  nature  of  its  service.  The  medical  school  cannot  then  escape 
social  criticism  and  regulation.  It  was  left  to  itself  while  society  knew  no  better.  But 
civilization  consists  in  the  legal  registration  of  gains  won  by  science  and  experience; 
and  science  and  experience  have  together  established  the  terms  upon  which  medicine 
can  be  most  useful.  "In  the  old  days,"  says  Metchnikoff,1  "anyone  was  allowed  to 
practise  medicine,  because  there  was  no  medical  science  and  nothing  was  exact.  Even 
at  the  present  time  among  less  civilized  people,  any  old  woman  is  allowed  to  be  a 
midwife.  Among  more  civilized  races,  differentiation  has  taken  place  and  childbh-ths 
are  attended  by  women  of  special  training  who  are  midwives  by  diploma.  In  case  of 
nations  still  more  civilized,  the  trained  midwives  are  directed  by  obstetric  physicians 
who  have  specialized  in  the  conducting  of  labor.  This  high  degree  of  differentiation 
has  arisen  with  and  has  itself  aided  the  progress  of  obstetrical  science.'1  Legislation 
l  Tht  Nature  of  Man  (translated  by  Chalmers),  p.  300. 


RECONSTRUCTION  155 

which  should  procure  for  all  the  advantage  of  such  conditions  as  is  now  possible 
would  speedily  bring  about  a  reconstruction  quite  as  extensive  as  that  described. 

Such  control  in  the  social  interest  inevitably  encounters  the  objection  that  indi- 
vidualism is  thereby  impaired.  So  it  is,  at  that  level;  so  it  is  intended.  The  commu- 
nity through  such  regulation  undertakes  to  abridge  the  freedom  of  particular  indi- 
viduals to  exploit  certain  conditions  for  their  personal  benefit.  But  its  aim  is  thereby 
to  secure  for  all  others  more  freedom  at  a  higher  level.  Society  forbids  a  company  of 
physicians  to  pour  out  upon  the  community  a  horde  of  ill  trained  physicians.  Their 
liberty  is  indeed  clipped.  As  a  result,  however,  more  competent  doctors  being  trained 
under  the  auspices  of  the  state  itself,  the  public  health  is  improved ;  the  physical 
well-being  of  the  wage- worker  is  heightened;  and  a  restriction  put  upon  the  liberty, 
so-called,  of  a  dozen  doctors  increases  the  effectual  liberty  of  all  other  citizens.  Has 
democracy,  then,  really  suffered  a  set-back?  Reorganization  along  rational  lines  in- 
volves the  strengthening,  not  the  weakening,  of  democratic  principle,  because  it  tends 
to  provide  the  conditions  upon  which  well-being  and  effectual  liberty  depend. 


CHAPTER  X 

THE   MEDICAL  SECTS 

Lv  the  reconstruction  just  sketched,  no  allusion  has  been  made  to  medical  sectarianism. 
We  have  considered  the  making  of  doctors  and  the  increase  of  knowledge;  allopathy, 
homeopathy,  osteopathy,  have  cut  no  figure  in  the  discussion.  Is  it  essential  that  we 
should  now  conclude  a  treaty  of  peace,  by  which  the  reduced  number  of  medical  schools 
shall  be  so  pro-rated  as  to  recognize  dissenters  on  an  equitable  basis? 

The  proposition  raises  at  once  the  question  as  to  whether  in  this  era  of  scientific 
medicine,  sectarian  medicine  is  logically  defensible;  as  to  whether,  while  it  exists, 
separate  standards,  fixed  by  the  conditions  under  which  it  can  survive,  are  justifi- 
able. Prior  to  the  placing  of  medicine  on  a  scientific  basis,  sectarianism  was,  of 
course,  inevitable.  Every  one  started  with  some  sort  of  preconceived  notion;  and 
from  a  logical  point  of  view,  one  preconception  is  as  good  as  another.  Allopathy 
was  just  as  sectarian  as  homeopathy.  Indeed,  homeopathy  was  the  inevitable  retort 
to  allopathy.  If  one  man  "believes"  in  dissimilars,  contrary  suggestion  is  certain 
to  provide  another  who  will  stake  his  life  on  similars;  the  champion  of  big  doses 
will  be  confronted  by  the  champion  of  little  ones.  But  now  that  allopathy  has  sur- 
rendered to  modern  medicine,  is  not  homeopathy  borne  on  the  same  current  into  the 
same  harbor? 

The  modern  point  of  view  may  be  restated  as  follows:  medicine  is  a  discipline,  in  which 
the  effort  is  made  to  use  knowledge  procured  in  various  ways  in  order  to  effect  cer- 
tain practical  ends.  With  abstract  general  propositions  it  has  nothing  to  do.  It  har- 
bors no  preconceptions  as  to  diseases  or  their  cure.  Instead  of  starting  with  a  finished 
and  supposedly  adequate  dogma  or  principle,  it  has  progressively  become  less  cock- 
sure and  more  modest.  It  distrusts  general  propositions,  a  priori  explanations,  gran- 
diose and  comforting  generalizations.  It  needs  theories  only  as  convenient  sum- 
maries in  which  a  number  of  ascertained  facts  may  be  used  tentatively  to  define  a 
course  of  action.  It  makes  no  effort  to  use  its  discoveries  to  substantiate  a  principle 
formulated  before  the  facts  were  even  suspected.  For  it  has  learned  from  the  previ- 
ous history  of  human  thought  that  men  possessed  of  vague  preconceived  ideas  are 
strongly  disposed  to  force  facts  to  fit,  defend,  or  explain  them.  And  this  tendency  both 
interferes  with  the  free  search  for  truth  and  limits  the  good  which  can  be  extracted 
from  such  truth  as  is  in  its  despite  attained. 

Modern  medicine  has  therefore  as  little  sympathy  for  allopathy  as  for  homeopathy. 
It  simply  denies  outright  the  relevancy  or  value  of  either  doctrine.  It  wants  not 
dogma,  but  facts.  It  countenances  no  presupposition  that  is  not  common  to  it  with 
all  the  natural  sciences,  with  all  logical  thinking. 

The  sectarian,  on  the  other  hand,  begins  with  his  mind  made  up.  He  possesses  in 
advance  a  general  formula,  which  the  particular  instance  is  going  to  illustrate,  verify, 


MEDICAL  SECTS  157 

reaffirm,  even  though  he  may  not  know  just  how.  One  may  be  sure  that  facts  so 
read  will  make  good  what  is  expected  of  them;  that  only  that  will  be  seen  which 
will  sustain  its  expected  function ;  that  every  aspect  noted  will  be  dutifully  loyal  to 
the  revelation  in  whose  favor  the  observer  is  predisposed:  the  human  mind  is  so 
constituted. 

It  is  precisely  the  function  of  scientific  method — in  social  life,  politics,  engineering, 
medicine — to  get  rid  of  such  hindrances  to  clear  thought  and  effective  action.  For 
it,  comprehensive  summaries  are  situate  in  the  future,  not  in  the  past;  we  shall  at- 
tain them,  if  at  all,  at  the  end  of  great  travail;  they  are  not  lightly  to  be  assumed 
prior  to  the  beginning.  Science  believes  slowly;  in  the  absence  of  crucial  demonstra- 
tion its  mien  is  humble,  its  hold  is  light.  "One  should  not  teach  dogmas;  on  the 
contrary,  every  utterance  must  be  put  to  the  proof.  One  should  not  train  disciples 
but  form  observers :  one  must  teach  and  work  in  the  spirit  of  natural  science."1 

Scientific  medicine  therefore  brushes  aside  all  historic  dogma.  It  gets  down 
to  details  immediately.  No  man  is  asked  in  whose  name  he  comes — whether  that 
of  Hahnemann,  Rush,  or  of  some  more  recent  prophet.  But  all  are  required  to 
undergo  rigorous  cross-examination.  Whatsoever  makes  good  is  accepted,  becomes 
in  so  far  part,  and  organic  part,  of  the  permanent  structure.  To  plead  in  advance 
a  principle  couched  in  pseudo-scientific  language  or  of  extra-scientific  character 
is  to  violate  scientific  quality.  There  is  no  need,  just  as  there  is  no  logical  justifi- 
cation, for  the  invocation  of  names  or  creeds,  for  the  segregation  from  the  larger 
body  of  established  truth  of  any  particular  set  of  truths  or  supposed  truths  as  es- 
pecially precious.  Such  segregation  may  easily  invest  error  with  the  sanctity  of  truth; 
it  will  certainly  result  in  conferring  disproportionate  importance  upon  the  fact  or  pro- 
cedure marked  out  as  of  pivotal  significance.  The  tendency  to  build  a  system  out  of 
a  few  partially  apprehended  facts,  deductive  inference  filling  in  the'rest,  has  not  in- 
deed been  limited  to  medicine,  but  it  has  nowhere  else  had  more  calamitous  conse- 
quences. 

The  logical  position  of  medical  sectarians  to-day  is  self-contradictory.  They  have 
practically  accepted  the  curriculum  as  it  has  been  worked  out  on  the  scientific  basis. 
They  teach  pathology,  bacteriology,  clinical  microscopy.  They  are  thereby  com- 
mitted to  the  scientific  method ;  for  they  aim  to  train  the  student  to  ascertain  and 
interpret  facts  in  the  accepted  scientific  manner.  He  may  even  learn  his  sciences  in 
the  same  laboratory  as  the  non-sectarian.  But  scientific  method  cannot  be  limited 
to  the  first  half  of  medical  education.  The  same  method,  the  same  attitude  of  mind, 
must  consistently  permeate  the  entire  process.  The  sectarian  therefore  in  effect  con- 
tradicts himself  when,  having  pursued  or  having  agreed  to  pursue  the  normal  scien- 
tific curriculum  with  his  student  for  two  years,  he  at  the  beginning  of  the  third  year 
produces  a  novel  principle  and  requires  that  thenceforth  the  student  effect  a  com- 
promise between  science  and  revelation. 
1  Johannes  Orth  :  Berliner  Klinische  Wochenschrift,  vol.  xliii.  p.  818. 


158  MEDICAL  EDUCATION 

Once  granted  the  possibility  of  medical  dogma,  there  can  be  no  limit  to  the  num- 
ber of  dissenting  sects.  As  a  matter  of  fact,  only  three  or  four  are  entitled  to  serious 
notice  in  an  educational  discussion.  The  chiropractics,  the  mechano- therapists,  and 
several  others  are  not  medical  sectarians,  though  exceedingly  desirous  of  masquerading 
as  such ;  they  are  unconscionable  quacks,  whose  printed  advertisements  are  tissues  of 
exaggeration,  pretense,  and  misrepresentation  of  the  most  unqualifiedly  mercenary 
character.  The  public  prosecutor  and  the  grand  jury  are  the  proper  agencies  for 
dealing  with  them. 

Sectarians,  in  the  logical  sense  above  discussed,  are  (1)  the  homeopathists,  (2)  the 
eclectics,  (3)  the  physiomedicals,  (4)  the  osteopaths.  All  of  them  accept  in  theory, 
at  least,  the  same  fundamental  basis.  They  admit  that  anatomy,  pathology,  bac- 
teriology, physiology,  must  form  the  foundation  of  a  medical  education,  to  use  the 
words  broadly  so  as  to  include  all  varieties  of  therapeutic  procedure.  They  offer  no 
alternative  to  pathology  or  physiology;  there  is,  they  concede,  only  one  proper 
science  of  the  structure  of  the  human  body,  of  the  abnormal  growths  that  afflict  it. 
So  far,  they  make  no  issue  as  against  scientific  medicine.  Much  is  involved  in  agree- 
ment up  to  this  point.  The  standards  of  admission  to  the  medical  school,  the  facili- 
ties which  the  schools  must  furnish  in  order  effectively  to  teach  the  fundamental 
branches,  are  the  same  for  all  alike.  A  student  of  homeopathy  or  of  osteopathy  needs 
to  be  just  as  intelligent  and  mature  as  a  student  of  scientific  medicine;  and  he  is  no 
easier  to  teach;  for  during  the  first  and  second  years,  at  least,  he  is  supposed  to  be 
doing  precisely  the  same  things. 

At  the  beginning  of  the  clinical  years,  the  sectarian  interposes  his  special  princi- 
ple. But  educationally,  the  conditions  he  needs  thenceforth  do  not  materially  differ 
from  those  needed  by  consistently  scientific  medicine.  Once  more,  whatever  the  ar- 
bitrary peculiarity  of  the  treatment  to  be  followed,  the  student  cannot  be  trained  to 
recognize  clinical  conditions,  to  distinguish  between  different  clinical  conditions,  or 
to  follow  out  a  line  of  treatment,  except  in  the  ways  previously  described  in  deal- 
ing with  scientific  medicine.  He  must  see  patients  and  must  follow  their  progress,  so 
as  to  discover  what  results  take  place  in  consequence  of  the  specific  measures  employed. 
A  sectarian  institution,  being  a  school  in  which  students  are  trained  to  do  particular 
things,  needs  the  same  resources  and  facilities  on  the  clinical  side  as  a  school  of  scien- 
tific medicine. 

Sectarian  institutions  do  not  exist  in  Canada ;  in  the  United  States  there  are  32 
of  them,  of  which  15  are  homeopathic,  8  eclectic,  1  physiomedical,  and  8  osteopathic. 
Without  attempting  to  indicate  the  peculiar  tenets  of  each,  we  shall  briefly  review 
them  as  schools,  seeking  to  ascertain  how  far  they  are  in  position  effectively  to  teach, 
quite  regardless  of  the  individual  doctrine  each  sect  may  desire  to  promote. 

None  of  the  fifteen  homeopathic  schools 1  requires  more  than  a  high  school  educa- 

1  Hahnemann  (San  Francisco),  Hahnemann  and  Hering  (Chicago),  state  universities  of  Iowa  and 
Michigan,  Southwestern  Homeopathic  (Louisville),  Boston  University,  Detroit  Homeopathic,  Kan- 


MEDICAL  SECTS  159 

tion  for  entrance ;  only  five1  require  so  much.  The  remaining  eleven  get  less, —  how 
much  less  depending  on  their  geographical  locations  rather  than  on  the  school^  own 
definition.  The  Louisville,  Kansas  City,  and  Baltimore  schools  cannot  be  said  to  have 
admission  standards  in  any  strict  sense  at  all ;  Pulte  at  Cincinnati  is  bound  to  be  care- 
ful in  dealing  with  Ohio  candidates:  outsiders  are  responsible  for  themselves.  The 
minimum  at  Boston  University,  to  judge  from  the  examinations  which,  in  default  of 
acceptable  credentials,  the  candidate  must  pass,  covers  less  than  two  years  of  a  good 
high  school  course. 

On  the  laboratory  side,  though  the  homeopaths  admit  the  soundness  of  the  sci- 
entific position,  they  have  taken  no  active  part  in  its  development.  Nowhere  in  homeo- 
pathic institutions,  with  the  exception  of  one  or  two  departments  at  Boston  Uni- 
versity, is  there  any  evidence  of  progressive  scientific  work.  Even  "drug  proving"  is 
rarely  witnessed.  The  fundamental  assumption  of  the  sect  is  sacred;  and  scientific 
activity  cannot  proceed  where  any  such  interdict  is  responsible  for  the  spirit  of  the 
institution.  The  homeopathic  departments  at  Iowa  and  Michigan  are  in  this  respect 
only  half-schools, — clinical  halves.  For  their  students  get  their  scientific  instruction 
in  pathology,  anatomy,  etc.,  in  the  only  laboratories  which  the  university  devotes  to 
those  subjects,  under  men  none  of  whom  sympathizes  with  homeopathy.  Their  dis- 
advantage is  increased  by  the  fact  that  the  instruction  is  adapted  to  students  who 
have  had  one  or  two  years  of  college  work.  The  general  argument  in  favor  of  higher 
standards  is  here  reinforced  by  the  consideration  that  the  homeopathic  students 
should  certainly  qualify  themselves  for  the  only  grade  of  scientific  instruction  that 
the  two  universities  offer. 

Of  complete  homeopathic  schools,  Boston  University,  the  New  York  Homeopathic 
College,  and  the  Hahnemann  of  Philadelphia  alone  possess  the  equipment  necessary 
for  the  effective  routine  teaching  of  the  fundamental  branches.  None  of  them  can 
employ  full-time  teachers  to  any  considerable  extent.  But  they  possess  fairly  well- 
equipped  laboratories  in  anatomy,  pathology,  bacteriology,  and  physiology,1  a  mu- 
seum showing  care  and  intelligence,  and  a  decent  library.  Boston  University  deserves 
especial  commendation  for  what  it  has  accomplished  with  its  small  annual  income. 

Of  the  remaining  homeopathic  schools,  four  are  weak  and  uneven:  the  Hahnemann 
of  San  Francisco  and  the  Hahnemann  of  Chicago  have  small,  but  not  altogether  in- 
adequate, equipment  for  the  teaching  of  chemistry,  elementary  pathology  and  bac- 
teriology ;  the  Cleveland  school  offers  an  active  course  in  experimental  physiology.  Be- 
yond ordinary  dissection  and  elementary  chemistry,  they  offer  little  else.  There  is, 
for  example,  no  experimental  physiology  in  the  San  Francisco  Hahnemann:  "the 
instructor  does  n't  believe  in  it;"  the  Chicago  Hahnemann  contains  a  small  outfit  and 

sas  City  (Kansas)  Hahnemann,  New  York  Medical  College  for  Women,  New  York  Homeopathic, 
Pulte  (Cincinnati),  Cleveland  Homeopathic,  Hahnemann  (Philadelphia),  Atlantic  Medical  (Baltimore). 

1  State  universities  of  Iowa  and  Michigan,  Detroit  Homeopathic,  and  the  two  New  York  schools. 

2  The  Philadelphia  Hahnemann  is  defective  in  experimental  physiology. 


160  MEDICAL  EDUCATION 

a  few  animals  for  that  subject;  the  Cleveland  equipment  for  pathology  and  bacteri- 
ology is  meager.  The  New  York  Homeopathic  College  for  Women  is  well  intentioned, 
but  its  means  have  permitted  it  to  do  but  little  in  any  direction. 

Six  schools  remain — all  utterly  hopeless:  Hering  (Chicago),  because  it  is  with- 
out plant  or  resources;  the  other  five,1  because  in  addition  to  having  nothing,  their 
condition  indicates  the  total  unfitness  of  their  managers  for  any  sort  of  educational 
responsibility.  The  buildings  are  filthy  and  neglected.  At  Louisville  no  branch  is 
properly  equipped ;  in  one  room,  the  outfit  is  limited  to  a  dirty  and  tattered  mani- 
kin; in  another,  a  single  guinea  pig  awaits  his  fate  in  a  cage.  At  Detroit  the  dean 
and  secretary  "have  their  offices  downtown;"  the  so-called  laboratories  are  in  utter 
confusion.  At  Kansas  City  similar  disorder  prevails.  At  the  Atlantic  Medical  ap- 
pearances are  equally  bad ;  to  make  matters  worse,  the  school  has  lately  omitted  the 
word  "homeopathic"  from  its  title  so  as  to  gather  in  students  dropped  from  other 
Baltimore  schools. 

In  respect  to  hospital  facilities,  the  University  of  Michigan,  Boston  University,  and 
the  New  York  Homeopathic  alone  command  an  adequate  supply  of  material,  under 
proper  control,  though  modern  teaching  methods  are  not  thoroughly  utilized  even  by 
them.  The  Iowa  school  controls  a  small,  but  inadequate,  hospital.  All  the  others  are 
seriously  handicapped  by  either  lack  of  material  or  lack  of  control,  and  in  most  instances 
by  both.  The  Hahnemann  of  San  Francisco  relies  mainly  on  30  beds  supported  by  the 
city  and  county  in  a  private  hospital ;  the  Detroit  school  is  cordially  welcome  at  the 
Grace  Hospital,  but  less  than  60  beds  are  available,  and  they  are  mostly  surgical ;  the 
Woman's  Homeopathic  of  New  York2  controls  a  hospital  of  35  available  beds,  mostly 
surgical ;  the  Southwestern  (Louisville)  and  the  Cleveland  school  get  one-fifth  of  the 
patients  that  enter  the  city  hospitals  of  their  respective  towns,  but  these  hospitals  are 
not  equipped  or  organized  with  a  view  to  teaching.  The  Kansas  City  school  holds 
clinics  one  day  a  week  at  the  City  Hospital ;  Pulte  (Cincinnati)  and  the  Atlantic 
(Baltimore)  have,  as  nearly  as  one  can  gather,  nothing  definite  at  all.  Several  of  the 
schools  appear  to  be  unnecessarily  handicapped.  The  Chicago  Hahnemann  adjoins 
a  hospital  with  60  ward  beds.  But  as  the  superintendent "  does  n't  believe  in  admitting 
students  to  wards,"  there  is  little  or  nothing  beyond  amphitheater  teaching.  A 
bridge  connects  Hering  (Chicago)  with  a  homeopathic  hospital,  but  "students  are 
not  admitted."  The  Cleveland  school  is  next  door  to  a  hospital  with  which  it  was  once 
intimate ;  their  relations  have  been  ruptured.  An  excellent  hospital  is  connected  with 
the  building  occupied  by  the  Philadelphia  Hahnemann,  but  there  is  no  ward  work. 

The  dispensary  situation  is  rather  worse.  Iowa  and  Ann  Arbor  have  little  oppor- 
tunity. Of  the  others,  Boston  University  alone  has  a  really  model  dispensary,  com- 
paring favorably  in  equipment,  organization,  and  conduct  with  the  best  institutions 

'Southwestern  (Louisville),  Pulte  (Cincinnati),  Atlantic  (Baltimore),  and  the  Detroit  and  Kansas 
City  schools. 

'This  school  has  scattered  supplementary  facilities,  as  is  the  way  of  New  York  schools. 


MEDICAL  SECTS  161 

of  the  kind  in  the  country.  The  New  York  Homeopathic,  the  Chicago  Hahnemann, 
and  the  Philadelphia  Hahnemann  command  material  enough.  The  others  lack  material, 
equipment,  or  care ;  in  some  instances, —  Atlantic  Medical,  Pulte,  Detroit,  Kansas 
City, — they  lack  everything  that  a  dispensary  should  possess. 

Financially,  the  two  state  university  departments  and  the  New  York  Homeo- 
pathic school  are  the  only  homeopathic  schools  whose  strength  is  greater  than  their 
fee  income.  All  the  others  are  dependent  on  tuition.  Their  outlook  for  higher  entrance 
standards  or  improved  teaching  is,  therefore,  distinctly  unpromising.  Only  a  few  of 
them  command  tuition  fees  enough  to  do  anything  at  all :  the  Chicago  Hahnemann, 
Boston  University,  and  the  Philadelphia  Hahnemann,  with  annual  fees  ranging  be- 
tween $12,000  and  $18,000.*  Nine  of  them  are  hopelessly  poor:  the  San  Francisco 
Hahnemann,  Hering  (Chicago),  the  Detroit  Homeopathic,  and  the  Atlantic  Medi- 
cal operate  on  less  than  $4000 J  a  year;  the  Southwestern  (Louisville)  and  Pulte 
(Cincinnati)  on  less  than  S1500.1 

In  the  year  1900  there  were  twenty-two  homeopathic  colleges  in  the  United 
States ;  to-day  there  are  fifteen ;  the  total  student  enrolment  has  within  the  same 
period  been  cut  almost  in  half,  decreasing  from  1909  to  1009  ;2  the  graduating 
classes  have  fallen  from  413  to  246.  As  the  country  is  still  poorly  supplied  with 
homeopathic  physicians,  these  figures  are  ominous ;  for  the  rise  of  legal  standard  must 
inevitably  affect  homeopathic  practitioners.  In  the  financial  weakness  of  their  schools, 
the  further  shrinkage  of  the  student  body  will  inhibit  first  the  expansion,  then  the 
keeping  up,  of  the  sect. 

Logically,  no  other  outcome  is  possible.  The  ebbing  vitality  of  homeopathic  schools 
is  a  striking  demonstration  of  the  incompatibility  of  science  and  dogma.  One  may 
begin  with  science  and  work  through  the  entire  medical  curriculum  consistently,  ex- 
posing everything  to  the  same  sort  of  test ;  or  one  may  begin  with  a  dogmatic  asser- 
tion and  resolutely  refuse  to  entertain  anything  at  variance  with  it.  But  one  cannot 
do  both.  One  cannot  simultaneously  assert  science  and  dogma;  one  cannot  travel 
half  the  road  under  the  former  banner,  in  the  hope  of  taking  up  the  latter,  too,  at 
the  middle  of  the  march.  Science,  once  embraced,  will  conquer  the  whole.  Homeopathy 
has  two  options:  one  to  withdraw  into  the  isolation  in  which  alone  any  peculiar 
tenet  can  maintain  itself;  the  other  to  put  that  tenet  into  the  melting-pot.  Histor- 
ically it  undoubtedly  played  an  important  part  in  discrediting  empirical  allopathy. 
But  laboratories  of  physiology  and  pharmacology  are  now  doing  that  work  far  more 
effectively  than  homeopathy;  and  they  are  at  the  same  time  performing  a  con- 
structive task  for  which  homeopathy,  as  such,  is  unfitted.  It  will  be  clear,  then,  why, 
when  outlining  a  system  of  schools  for  the  training  of  physicians  on  scientific  lines, 
no  specific  provision  is  made  for  homeopathy.  For  everything  of  proved  value  in 

1  Estimated. 

2  Journal  of  the  American  Institute  of  Homeopathy,  vol.  i.,  1909,  no.  11,  p.  537.  The  Journal  of  the 
American  Medical  Association,  Aug.  14,  1909  (pp.  556,  557),  gives  figures  somewhat  lower:  889  instead 
of  1009 ;  209  instead  of  246.  The  discrepancy  does  not  alter  our  interpretation. 


162  MEDICAL  EDUCATION 

homeopathy  belongs  of  right  to  scientific  medicine  and  is  at  this  moment  incorpo- 
rate in  it;  nothing  else  has  any  footing  at  all,  whether  it  be  of  allopathic  or  homeo- 
pathic lineage.  "A  new  school  of  practitioners  has  arisen,"  says  Dr.  Osier,  "which 
cares  nothing  for  homeopathy  and  less  for  so-called  allopathy.  It  seeks  to  study,  ra- 
tionally and  scientifically,  the  action  of  drugs,  old  and  new."1 

There  are  eight  eclectic  schools.2  One  of  them  —  that  in  New  York  City  —  requires 
the  Regents'  Medical  Student  Certificate,  i.  e.,  a  four-year  high  school  education, 
for  admission;  the  Cincinnati  school  must  require  an  equal  preliminary  education  of 
students  expecting  to  practise  in  Ohio,  others  taking  the  matter  into  their  own 
hands.  Just  how  the  instruction  is  thus  accommodated  to  various  levels  is  not  clear. 
The  remaining  six  schools  have  either  nominal  requirements  or  none  at  all. 

None  of  the  schools  has  anything  remotely  resembling  the  laboratory  equipment 
which  all  claim  in  their  catalogues.  The  Cincinnati  institution  possesses  a  new  and 
attractive  building,  thus  far  meagerly  fitted  out;  the  New  York  school  has  a  clean 
building  with  a  chemical  laboratory  in  which  elementary  chemistry  can  be  and  ap- 
parently is  taught  properly.  It  has  little  else:  a  small  room  for  the  microscopic  sub- 
jects, but  no  adequate  equipment  for  teaching  them;  a  few  thousand  books,  mostly 
old ;  a  few  models,  a  lantern,  etc.,  —  and  this  is  most  satisfactorily  equipped  of  all  the 
eclectic  institutions.  The  Hospital  School  at  Atlanta,  starting  on  four  weeks'1  notice, 
had  time  to  get  students,  but  not  to  get  means  of  teaching  them.  The  private  labora- 
tory of  the  instructor  in  pathology  and  bacteriology  was  meanwhile  at  their  service: 
other  equipment  there  was,  at  the  time  of  the  visit,  none. 

The  remaining  five  eclectic  schools  are  without  exception  filthy  and  almost  bare. 
They  have  at  best  grimy  little  laboratories  for  elementary  chemistry,  a  few  micro- 
scopes, some  bottles  containing  discolored  and  unlabeled  pathological  material,  an 
incubator  out  of  commission,  and  a  horrid  dissecting-room, — when  dissecting  is  in 
progress.  The  St.  Louis  school  was  the  proud  possessor  of  some  new  physiological 
apparatus,  the  state  board  having  recently  issued  an  edict  requiring  its  purchase;  but 
there  was  no  place  to  use  it  and  no  sign  of  its  use.  The  Kansas  City  institution  had 
likewise  made  a  recent  investment  to  the  same  extent,  having  just  taken  on  the  fa- 
culty the  "laboratory  man"  of  the  local  homeopathic  and  osteopathic  schools.  The 
other  Atlanta,  the  Los  Angeles,  and  the  Lincoln  schools  have  even  less.  The  Lin- 
coln institution  alleges  that  its  scientific  training  is  given  at  Cotner  University,  where 
the  only  material  available  for  medical  instruction  consists  of  a  chemical  laboratory, 
some  microscopes,  and  a  small  collection  of  stuffed  birds. 

Of  the  eight  schools  under  discussion,  none  has  decent  clinical  opportunities.  The 
New  York  school  can  send  three  students  twice  weekly  to  the  Sydenham  Hospital; 
the  Cincinnati  school  is  affiliated  with  the  Seton  Hospital,  with  24  available  beds, 

lLoc.  dt.,  p.  268. 

*One  each  at  Los  Angeles,  Kansas  City  (Kansas),  St  Louis,  Lincoln  (Nebraska),  Cincinnati,  New 
York  City,  and  two  at  Atlanta. 


MEDICAL  SECTS  168 

80  to  90  per  cent  surgical,  and  can  send  its  men  to  look  on  at  the  public  clinics 
given  in  the  City  Hospital;  the  St.  Louis  students  have  a  day  a  week  at  the  City 
Hospital  and  profit  occasionally  elsewhere  through  professorial  connection.  All  this 
is  criminally  inadequate,  yet  it  is  the  best  that  the  eclectics  offer;  for  the  other  five 
schools  have  literally  nothing  at  all.  One  of  the  Atlanta  "  colleges'"  is  connected  with 
a  private  infirmary ;  the  other  has  not  even  such  a  semblance.  The  Los  Angeles  school 
claims  "  private  hospitals  only ; "  the  Kansas  City  school  claims  to  give  clinics  at  the 
new  City  Hospital,  but  the  hospital  authorities  deny  it.  At  Lincoln  "  there  are  no 
regular  hours  at  any  hospital ;  they  depend  on  cases  as  they  turn  up." 

The  dispensaries  may  be  even  more  briefly  described.  The  Atlanta,  Lincoln,  and 
Los  Angeles  schools  have  none  at  all.  The  Cincinnati  school  uses  poorly  the  small 
dispensary  at  the  Seton  Hospital.  The  New  York  school  has  three  rooms  in  its  own 
building  and  access  to  another  dispensary.  At  St.  Louis  there  is  one  room  and  "  some 
one  comes  almost  every  day ; "  at  Kansas  City,  one  room  likewise,  with  a  present  daily 
attendance  of  three  and  a  confident  aspiration  that  this  number  can  be  swelled  to  six. 

The  utter  hopelessness  of  the  future  of  these  schools  is  apparent  on  a  glance  at 
their  financial  condition.  All  are  dependent  on  fees.  Only  three  of  them  —  the  New 
York,  the  Cincinnati,  and  one  Atlanta  school — enjoy  an  income  between  $5000  and 
$8500 J  a  year;  the  St.  Louis,  Lincoln,  and  second  Atlanta  schools  have  something 
over  $3000 1  annually ;  those  at  Los  Angeles  and  Kansas  City  not  much  above  $1000 ; 1 
and  these  modest  sums  are  not  always  spent  within  the  schools.  Statistics  confirm  the 
unfavorable  prognosis :  the  ten  schools  which  the  sect  possessed  in  1901  have  now 
dwindled  to  eight ;  a  maximum  enrolment  of  1014  in  1904  has  already  shrunk  to  413 ; 
graduates  numbered  186  in  1906,  84  in  1909. 

So  far  as  sectarian  creeds  go,  there  is,  of  course,  no  reason  why  these  schools  should 
be  elaborately  equipped  for  scientific  instruction.  They  talk  of  laboratories,  not  be- 
cause they  appreciate  their  place  or  significance,  but  because  it  pays  them  to  defer 
thus  far  to  the  spirit  of  the  times.  Culpable  indeed  they  are,  however,  for  their  utter 
failure  to  make  good  what  their  own  tenets  prescribe.  The  eclectics  are  drug  mad ; 
yet,  with  the  exception  of  the  Cincinnati  and  New  York  schools,  none  of  them  can 
do  justice  to  its  own  creed.  For  they  are  not  equipped  to  teach  the  drugs  or  the  drug 
therapy  which  constitutes  their  sole  reason  for  existence.2 

The  eight  osteopathic  schools3  fairly  reek  with  commercialism.  Their  catalogues  are 
a  mass  of  hysterical  exaggerations,  alike  of  the  earning  and  of  the  curative  power  of 
osteopathy.  It  is  impossible  to  say  upon  which  score  the  "  science "  most  confidently 
appeals  to  the  crude  boys  or  disappointed  men  and  women  whom  it  successfully 

1  Estimated. 

2  The  physio-medical  sect  can  be  dismissed  in  a  note.  It  had  three  schools  in  1907;  only  one,  that  in 
Chicago,  is  left.  The  reader  will  find  it  described  in  Part  II,  under  Illinois,  no.  (11).  There  were  149 
physio-medical  students  in  1904;  there  are  now  52;  there  were  20  graduates  in  that  year,  15  in  1909. 

3 One  school  is  found  in  each  of  the  following  cities:  Chicago,  Des  Moines,  Kirksville  (Missouri), 
Kansas  City  (Missouri),  Philadelphia,  Cambridge  (Massachusetts),  and  two  at  Los  Angeles. 


164  MEDICAL  EDUCATION 

exploits.  "In  no  case  has  a  competent  osteopath  made  a  failure  in  his  attempt  to  build 
up  a  paying  practice.  . . .  His  remuneration,  counted  in  dollars,  will  be  greatly  in  excess 
of  what  he  could  reasonably  expect  in  most  other  lines  of  professional  work." l  "  It  is 
only  fair  to  say  that  many  of  our  graduates  are  earning  as  much  in  single  months 
as  they  were  formerly  able  to  earn  by  a  full  year's  work." 8  "  The  average  osteopath 
has  a  better  practice  than  ninety  out  of  every  hundred  medical  practitioners.1"8  "  A 
lucrative  practice  is  assured  to  every  conscientious  and  capable  practitioner."  *  "The 
graduate  who  does  not  make  as  much  as  the  total  cost  of  his  osteopathic  education 
in  his  first  year  of  practice  is  the  exception." 6  Standards  these  concerns  have  none ; 
the  catalogues  touch  that  point  very  tenderly.  At  the  parent  school  at  Kirksville  an 
applicant  will  be  accepted  "  if  he  pass  examinations  in  English,  arithmetic,  history, 
and  geography ;"  but  if  he  should  fail  to  meet  these  lofty  scholastic  requirements, 
he  may  be  admitted  anyway.  In  Massachusetts — the  most  homogeneously  educated 
state  in  the  Union  —  the  Cambridge  school  diplomatically  posits  that  "  a  diploma 
may  be  accepted  or  an  examination  be  required  if  deemed  advisable  by  the  directors," 
—  the  word  "  is  "  being  conspicuous  by  its  absence ;  the  Pacific  College,  "  chancing 
it,"  finds  that  "  most  make  good." 

Whatever  his  notions  on  the  subject  of  treatment,  the  osteopath  needs  to  be  trained 
to  recognize  disease  and  to  differentiate  one  disease  from  another  quite  as  carefully  as 
any  other  medical  practitioner.  Our  account  of  the  sect  proceeds  wholly  from  this  point 
of  view.  Whether  they  use  drugs  or  do  not  use  them,  whether  some  use  them  while 
others  do  not,  does  not  affect  this  fundamental  question.  Whatever  they  do,  they  must 
know  the  body,  in  health  and  disease,  before  they  can  possibly  know  whether  there 
is  an  occasion  for  osteopathic  intervention,  and  if  so,  at  what  point,  to  what  extent,  etc. 
All  physicians,  summoned  to  see  the  sick,  are  confronted  with  precisely  the  same  crisis : 
a  body  out  of  order.  No  matter  to  what  remedial  procedure  they  incline,  —  medical, 
surgical,  or  manipulative, — they  must  first  ascertain  what  is  the  trouble.  There  is  only 
one  way  to  do  that.  The  osteopaths  admit  it,  when  they  teach  physiology,  pathology, 
chemistry,  microscopy.  Let  it  be  stated,  therefore,  with  all  possible  emphasis  that  no 
one  of  the  eight  osteopathic  schools  is  in  position  to  give  such  training  as  osteopathy  it- 
self demands.  The  entire  course  is  only  three  years.  In  so  simple  and  fundamental  a  mat- 
ter as  anatomy — assuredly  the  corner-stone  of  a  "science"  that  relies  wholly  on  local 
manipulation — they  are  fatally  defective.  At  Kirksville  the  accommodations  are  en- 
tirely unequal  to  the  teaching  of  its  huge  student  body.  Hence  the  first  year  is  devoted 
to  text-book  study  of  anatomy,  part  of  the  second  year  to  dissection ;  at  Kansas  City 
they  consider  that  the  student  dissects  better  if  he  has  learned  anatomy  first:  hence 

1  Catalog**,  Pacific  College  of  Osteopathy,  1909-10,  p.  9. 

1  Catalogue,  Los  Angeles  College  of  Osteopathy,  1909-10,  p.  9. 

^Catalogue,  Central  College  of  Osteopathy,  1908-9,  p.  22. 

«  Catalog**,  Philadelphia  College  of  Osteopathy,  1909-10,  p.  48. 

•  Catalogue,  Massachusetts  College  of  Osteopathy,  1909-10,  p.  10. 


MEDICAL  SECTS  165 

dissection  comes  in  the  latter  half  of  the  course,  being  completed  just  one-half  year 
before  graduation.  The  supply  of  material  is  also  scant :  the  school  had  had  one  ca- 
daver early  in  the  fall  and  was  looking  ahead  to  a  second  the  latter  part  of  the 
winter.  The  Los  Angeles  college  has  a  small  room  with  five  tables  for  a  student  body 
numbering  250;  it  solves  the  difficulty  by  giving  separate  squads  two  hours  a  week 
each.  At  Philadelphia  the  department  of  anatomy  occupies  an  outhouse,  whence  the 
noisome  odor  of  decaying  cadavers  permeates  the  premises.  Other  subjects  fare  even 
worse.  A  small  chemical  laboratory  is  occasionally  seen, — at  Philadelphia  it  happens 
to  be  in  a  dark  cellar.  At  Kirksville  a  fair-sized  room  is  devoted  to  pathology  and 
bacteriology ;  the  huge  classes  are  divided  into  bands  of  32,  each  of  which  gets  a  six 
weeks1  course,  following  the  directions  of  a  rigid  syllabus  under  a  teacher  who  is 
himself  a  student.  At  Cambridge  pathology  comes  in  the  last  year.  A  professor  in 
the  Kansas  City  school  said  of  his  own  institution  that  it  had  practically  no  labora- 
tories at  all ;  the  Still  College  at  Des  Moines  has,  in  place  of  laboratories,  laboratory 
signs;  the  Littlejohn  at  Chicago,  whose  catalogue  avers  that  the  "physician  should 
be  imbued  with  a  knowledge  of  the  healing  art  in  its  widest  fields,  and  here  is  the 
opportunity," 1  has  lately  in  rebuilding  wrecked  all  its  laboratories  but  that  of  chem- 
istry without  in  the  least  interfering  with  its  usual  pedagogic  routine.2 

Nowhere  is  there  the  faintest  effort  to  connect  the  "laboratory  teaching "  with 
"clinical  osteopathy ; "  perhaps  because  no  school  has  anything  approaching  the  re- 
quisite clinical  opportunities.  Once  more,  their  tenets  are  not  in  question.  Much  dif- 
ference of  opinion  prevails  among  them  as  to  whether  they  should  teach  everything  or 
only  some  things;  as  to  whether  they  may  use  drugs  in  certain  conditions  or  must 
confine  themselves  wholly  to  manipulation  for  "  osteopathic  lesions."  Howeverthis  may 
be,  the  osteopath  cannot  learn  his  technique  and  when  it  is  applicable,  except  through 
experience  with  ailing  individuals.  And  these,  for  the  most  part,  he  begins  to  see 
only  when  his  prosperity  begins  after  receiving  his  "D.O."  degree.  The  Kirksville 
school  (560  students)  has  indeed  a  hospital  of  54  beds,  of  which,  however,  only  20 
are  in  the  wards,  and  practically  all  are  surgical.  Eight  obstetrical  cases  were  obtained 
in  April  and  May  of  last  year.  The  Des  Moines  and  Kansas  City  schools  have  no 
hospitals  at  all;  the  students  see  no  acute  cases  "unless  the  doctors  can  take  them 
along."  The  Pacific  College  has  a  hospital  of  from  twelve  to  fifteen  surgical  and  ob- 
stetrical beds,  all  pay ;  "  the  students  have  no  regular  work  at  the  hospital  as  there 
are  so  few  acute  cases;  they  don't  see  as  much  acute  work  as  they  should,  but  they 
treat  everything."  The  Littlejohn  (Chicago)  has  also  a  pay  hospital,  of  20  beds, 
mostly  surgical.  The  Philadelphia  school,  whose  "opportunities  for  practical  work" 
are  highly  extolled  in  its  catalogue,  has  an  infirmary  with  three  beds,  occupied  by 


1  Bulletin,  June  15,  1909,  p.  7. 

'This  school  teaches  medicine  as  well  as  osteopathy.  It  offers  instruction  in  materia  medica  and 

therapeutics,  practice  of  medicine, — and  yet  it  is  a  three-year  school. 


166  MEDICAL  EDUCATION 

maternity  cases  if  at  all ;  the  Cambridge  student  must  travel  an  hour  or  more  to  the 
Chelsea  Hospital,  a  pay  institution  of  from  ten  to  fifteen  rooms. 

The  mercenary  character  of  osteopathic  instruction  is  nowhere  more  conspicuously 
displayed  than  in  the  dispensaries,  designed  in  theory  to  turn  a  humanitarian  im- 
pulse to  educational  account.  The  osteopathic  schools  insert  a  cash  nexus :  the  patients 
almost  always  pay.  At  Kansas  City  students  give  treatment  to  patients  who  pay 
three  dollars  a  month;  those  paying  more  are  treated  by  the  professors.  At  Kirks- 
ville  two  dollars  a  treatment  is  charged.  The  cases  are  mostly  chronics,  an  instructor 
being  present  at  the  first  treatment;  afterwards,  only  if  summoned.  At  Los  Angeles 
the  cheapest  obtainable  treatment  is  three  dollars  for  " examination  "  and  one  month's 
treatment  before  the  class;  at  Des  Moines  the  "professor  administers  to  high-priced 
patients,  the  students  to  others." 

The  eight  osteopathic  schools  now  enroll  over  1300  students,  who  pay  some  $200,000 
annually  in  fees.  The  instruction  furnished  for  this  sum  is  inexpensive  and  worthless. 
Not  a  single  full-time  teacher  is  found  in  any  of  them.  The  fees  find  their  way  di- 
rectly into  the  pockets  of  the  school  owners,  or  into  school  buildings  and  infirmaries 
that  are  equally  their  property.  No  effort  is  anywhere  made  to  utilize  prosperity  as 
a  means  of  defining  an  entrance  standard  or  developing  the  "science."1  Granting  all 
that  its  champions  claim,  osteopathy  is  still  in  its  incipiency.  If  sincere,  its  votaries 
would  be  engaged  in  critically  building  it  up.  They  are  doing  nothing  of  the  kind. 
Indeed,  in  none  of  the  sectarian  schools  does  one  observe  progressive  effort  even  along 
the  lines  of  its  own  creed.  And  very  naturally :  dogma  is  sufficient  unto  itself.  It  may 
not  search  its  own  assumptions ;  it  does  well  to  adopt  from  the  outside,  after  forced 
restatement  in  its  own  terms.2 

In  dealing  with  the  medical  sectary,  society  can  employ  no  special  device.  Certain 
profound  characteristics  in  one  way  or  another  support  the  medical  dissenter :  now, 
the  primitive  belief  in  magic  crops  up  in  his  credulous  respect  for  an  impotent  drug; 
again,  all  other  procedure  having  failed,  what  is  there  to  lose  by  flinging  one's  self 
upon  the  mercy  of  chance?  Instincts  so  profound  cannot  be  abolished  by  statute.  But 
the  limits  within  which  they  can  play  may  be  so  regulated  as  to  forbid  alike  their 
commercial  and  their  crudely  ignorant  exploitation.  The  law  may  require  that  all 
practitioners  of  the  healing  art  comply  with  a  rigidly  enforced  preliminary  educa- 
tional standard;  that  every  school  possess  the  requisite  facilities;  that  every  licensed 
physician  demonstrate  a  practical  knowledge  of  the  body  and  its  affections.  To  these 
terms  no  reasonable  person  can  object;  the  good  sense  of  society  can  enforce  them 
upon  reasonable  and  unreasonable  alike.  From  medical  sects  that  can  live  on  these 
conditions,  the  public  will  suffer  little  more  harm  than  it  is  destined  to  suffer  any- 
how from  the  necessary  incompleteness  of  human  knowledge  and  the  necessary  defects 
of  human  skill. 

1  At  the  Pacific  College  of  Osteopathy  alone  were  two  workers  doing  some  research. 
3  In  this  fashion  homeopathy  handles  serum-therapy  as  a  case  of  similars. 


CHAPTER  XI 

THE  STATE  BOARDS 

THE  state  boards  are  the  instruments  through  which  the  reconstruction  of  medical 
education  will  be  largely  effected.  To  them  the  graduate  in  medicine  applies  for  the 
license  to  practise.  Their  power  can  be  both  indirectly  and  directly  exerted.  They  may 
after  examination  reject  an  applicant, —  an  indirect  method  of  discrediting  the  school 
which  has  vouched  for  him  by  conferring  its  M.D.  degree.  A  small  percentage  of 
failures  the  doctrine  of  chance  would  lead  one  to  expect ;  an  increasing  proportion 
must  cast  increasingly  serious  doubt  on  any  institution.  A  more  direct  and  therefore 
more  salutary  method  is  needed,  however,  in  dealing  with  schools  bad  beyond  a 
reasonable  doubt.  In  such  instances  the  board  should  summarily  refuse  to  entertain 
the  applicant's  petition  because  his  medical  education  rests  upon  no  proper  prelim- 
inary training  or  was  received  under  conditions  that  forbade  thorough  or  conscientious 
instruction :  the  full  weight  of  its  refusal  would  fall  with  crushing  effect  upon  the 
school  which  sent  him  forth.  No  institution  can  long  survive  the  day  upon  which  it 
is  thus  publicly  branded  as  feeble,  unfit,  or  disreputable.  For  the  purpose,  however, 
of  saving  the  victims  whose  cruel  disappointment  will  in  time  destroy  these  schools, 
the  arm  of  the  state  boards  should  for  the  present  go  beyond  the  rejection  of  individ- 
uals to  the  actual  closing  up  of  notoriously  incompetent  institutions.  The  law  that 
protects  the  public  against  the  unfit  doctor  should  in  fairness  protect  the  student 
against  the  unfit  school. 

With  the  manifold  duties  and  responsibilities  of  the  state  boards  we  cannot  here 
fully  deal.  Our  attention  is  necessarily  confined  to  their  educational  function.  They 
examine  candidates  for  license ;  but  admission  to  examination  should  be  granted  only 
after  a  fair  presumption  of  intellectual  fitness  in  favor  of  the  applicant  has  been  es- 
tablished by  the  record  of  his  preliminary  education,  and  a  fair  presumption  of  suffi- 
cient professional  training  by  his  graduation  from  a  recognized  or  reputable  medical 
school.  Neither  of  these  points  can  for  the  present  be  overlooked.  So  long  as  the 
medical  school  has  as  such  no  determinate  position  in  the  school  system,  the  public 
health  authorities  must  be  empowered  to  fix  at  least  the  lowest  point  to  which  it  can 
safely  be  permitted  to  fall ;  moreover,  so  long  as  any  group  of  physicians  may  in  most 
states  incorporate  a  medical  school  under  general  laws  that  offer  no  safeguard  at  all, 
and  license  examinations  are  not  yet  deliberately  constructed  to  frustrate  their  ac- 
tivity, summary  protective  power  against  mercenary  and  incompetent  faculties  must 
be  lodged  somewhere.  The  boards  therefore  touch  at  three  points  the  problems  with 
which  this  report  has  dealt :  for  they  deal  (1 )  with  the  preliminary  educational  require- 
ment, (2)  with  the  facilities  of  medical  schools,  (3)  with  examinations  for  licensure. 

In  all  these  respects,  the  scope  of  the  state  board  is  of  course  determined  by  statute. 
Let  us  consider  briefly  what  powers  in  respect  to  each  are  needed  if  the  boards  are 


168  MEDICAL  EDUCATION 

to  be  effective  in  the  reconstruction  to  which  we  look  forward. 

(1)  However  the  educational  prerequisite  be  defined,  the  board  must  be  authorized 
to  insist  upon  it  as  an  educational,  and  not  as  a  practice,  preliminary.  The  sole  reason 
for  a  preliminary  requirement  of  any  kind  is  as  a  method  of  restricting  the  study  of 
medicine  to  those  in  whose  favor  an  initial  presumption  of  fitness  exists.  An  ordi- 
nary secondary  school  education  may  be  taken  as  indicating  minimum  competency 
only  if  it  chronologically  precede  admission  to  the  medical  school.  As  a  matter  of 
fact,  some  state  boards  legally  empowered  to  enforce  the  high  school  basis  are  often 
strangely  careless  as  to  the  significance  of  dates ;  so  that  a  requirement  whose  sole 
value  resides  in  its  priority  to  medical  education  is  held  to  be  satisfied  if  fulfilled 
just  prior  to  graduation  or  to  licensure. 

The  evaluation  of  preliminary  credentials  is  a  task  requiring  expert  knowledge 
and  experience.  Certain  boards  have  striven  hard  to  discharge  this  function  effectively ; 
but  they  lack  an  organization  competent  to  deal  with  it.  It  may  be  that  as  the 
feasibility  of  federated  action  is  increased  by  an  approach  to  uniformity  in  laws  and 
ideals,  a  central  authority  can  be  constituted  by  voluntary  cooperation  of  the  state 
boards,  maintained  by  contributions  from  their  several  funds,  and  charged  with  the 
business  of  procuring  first-hand  information  respecting  secondary  schools  and  col- 
leges. Such  an  agency  could,  by  communication  with  the  proper  educational  organi- 
zations engaged  in  the  study  and  improvement  of  secondary  schools,  command  reliable 
data  for  the  evaluation  of  credentials  prior  to  matriculation.  In  default  thereof,  the 
board  of  each  state,  instead  of  endeavoring  to  act  on  such  knowledge  as  it  can  ob- 
tain, should  get  at  once  into  effective  relations  with  the  state  university,  or  with  some 
endowed  institution  accustomed  to  pass  upon  questions  of  this  kind ;  and  the  medi- 
cal schools  should  be  compelled  to  have  a  student's  application  "  vised  "  by  the  state 
board  before  matriculation  is  regarded  as  complete.  If  neither  time  nor  subject  credit 
could  be  given  by  the  medical  school  for  any  work  prior  to  completed  matriculation, 
an  actual  four-year  high  school  preliminary  requirement  would  be  in  force.1 

(2)  The  enforcement  of  even  the  four-year  high  school  standard  will  so  far  clean 
up  the  medical  field  that  the  state  boards  will  at  once  be  relieved  of  the  duty  of 
dealing  with  actually  disreputable  schools.  Until  that  has  been  accomplished,  these 
boards  should  be  empowered  to  refuse  applications  from  the  graduates  of  schools 
scandalously  defective  in  teaching  facilities.  The  power  here  in  question,  if  extended 
too  far,  would  involve  serious  dangers.  For  boards  authorized  to  decide  whether 
schools  are  satisfactory  may  be  led  to  specify  the  details  which  determine  their  judg- 
ment. In  some  quarters  they  have  already  shown  a  tendency  to  prescribe  minutely 
the  contents  of  a  proper  medical  education.  Their  motive  has  been  excellent ;  they 
have  tried  to  compel  poor  schools  to  give  a  good  education.  Unfortunately,  that  is 
quite  impossible:  teachers  may  sign  a  register  showing  due  attendance  upon  their 
classes,  just  as  students  may  scrupulously  attend  specified  exercises  in  every  essen- 
1Thc  same  process  can  be  employed  in  the  south  to  enforce  whatever  standard  is  there  decided  on. 


THE  STATE  BOARDS  169 

tial  branch  for  a  fixed  number  of  hours;  but  the  instruction  will  probably  be  no 
whit  improved  by  such  police  regulation.  Meanwhile  every  competent  and  earnest 
instructor  is  seriously  hampered  by  the  vain  effort  to  aid  those  who  are  beyond  hu- 
man help.  The  fact  is  that  an  enforced  entrance  requirement  at  one  end  and  a  proper 
examination  at  the  other  will  of  themselves  limit  the  survival  of  schools  to  those  that 
are  financially  and  educationally  competent.  Only  so  long  as  an  entrance  requirement 
cannot  be  enforced  or  a  proper  examination  arranged,  do  the  state  boards  need  the 
power  to  close  schools  obviously  and  notoriously  defective. 

(3)  The  examination 1  for  licensure  is  indubitably  the  lever  with  which  the  entire 
field  may  be  lifted ;  for  the  power  to  examine  is  the  power  to  destroy.  At  present, 
these  examinations  are  not  only  without  stimulating  effect;  they  are  actually  depress- 
ing. There  is  only  one  sort  of  licensing  test  that  is  significant,  viz.,  a  test  that  ascer- 
tains the  practical  ability  of  the  student  confronting  a  concrete  case  to  collect  all 
relevant  data  and  to  suggest  the  positive  procedure  applicable  to  the  conditions 
disclosed.  A  written  examination  may  have  some  incidental  value;  it  does  not  touch 
the  heart  of  the  matter.  It  tends,  indeed,  to  do  just  the  reverse.  Written  examinations 
are  notably  apt  to  follow  beaten  paths.  A  collection  of  state  board  examinations 
covering  even  a  brief  period  of  years  will  contain  most  of  the  questions  that  will  be 
asked  hereafter.  An  effective,  but  purely  mechanical  and  entirely  useless  drill  may  be 
employed  to  make  examination-proof  a  student  who  in  the  presence  of  a  sick  person 
would  be  quite  helpless.  As  a  matter  of  fact,  prominent  publishers  put  forth  "State 
Board  Questions"  and  "Quiz-compends"  with  "  answers."  These  manuals,  well  conned, 
guarantee  the  candidate's  safety.  Do  not  the  several  states  appear  to  do  almost 
everything  in  their  power  to  resist  the  production  of  a  well  trained  body  of  physi- 
cians? In  the  first  place,  they  permit  a  half-dozen  men  to  start  a  medical  school  as 
lightly  as  they  permit  them  to  open  a  printing-shop;  and  they  then  offer  them  every 
inducement  to  furnish  poor  training  by  permitting  the  graduates  to  undergo  an  ex- 
amination for  which  they  can  satisfactorily  prepare  by  an  inexpensive  drill  that  has 
no  bearing  on  the  practical  ends  for  which  doctors  are  needed.  A  proper  examination 
would  go  far  to  correct  all  the  defects  that  this  report  has  sought  to  point  out.  For 
low  entrance  standards,  deficient  equipment,  bad  teaching,  lack  of  clinical  material, 
failure  to  correlate  laboratory  and  clinic,  would  be  detected  and  punished  by  a 
searching  practical  examination. 

If  the  written  examination  were  relegated  to  a  subordinate  position,  the  weight  of 
the  test  would  fall  upon  the  applicant's  ability  to  do  things;  schools  incapable  for 
whatever  reason  of  training  students  in  the  necessary  technique  would  be  rapidly  ex- 
posed through  the  annual  publication  of  statistics  proclaiming  their  failure.  The 
state  board  results,  now  so  frequently  misleading,  would  be  a  trustworthy  index  which 
the  more  intelligent  students  would  carefully  scan;  and  those  schools  only  would  sur- 

1  For  an  excellent  discussion,  see  Councilman :  "  Methods  and  Objects  of  State  Board  Examinations," 
Journal  of  American  Medical  Association,  Aug.  14,  1909,  pp.  515-19. 


170  MEDICAL  EDUCATION 

vive  whose  records  entitle  them  to  live.  Of  such  overwhelming  importance,  indeed, 
is  the  character  of  the  license  examination  that,  if  thorough  practical  examinations 
were  instituted,  all  the  other  perplexing  details  we  have  discussed  would  become  rel- 
atively immaterial. 

How  far  we  now  are  from  this  ideal  realized  in  other  countries,  hardly  aspired 
to  in  America,  a  few  facts  make  plain.  In  1906,  the  worst  of  the  Chicago  schools — 
a  school  with  no  entrance  requirement,  no  laboratory  teaching,  no  hospital  connec- 
tions— made  before  state  boards  the  best  record  attained  by  any  Chicago  school  in 
that  year.  This  school,  essentially  the  same  now  as  then,  has  only  recently  been  de- 
clared "not  in  good  standing"  with  the  state  board  of  Illinois.  Everywhere  in  Can- 
ada and  the  United  States  wretched  institutions  refute  criticism  by  pointing  to  their 
successful  state  board  records.  Halifax  and  Western  University  candidates  pass  in 
Canada  side  by  side  with  students  from  McGill  and  Toronto,  though  not  in  an  equal 
proportion;  for  even  in  the  written  examination,  better  opportunities  tell  in  the  long 
run.  Good  didactic  teaching  at  Bowdoin  or  Dartmouth  proves  capable  of  satisfying 
examinations  that  should  strongly  stress  clinical  experience.  One  or  two  of  the  states 
have  latterly  begun  to  introduce  certain  practical  features  into  their  examinations. 
These  timid  beginnings  are  hopeful  signs,  as  yet,  however,  hardly  extensive  enough 
anywhere  materially  to  affect  either  the  kind  of  teaching  employed  or  the  outcome 
of  the  examination.  The  army  and  navy  have  gone  a  little  further  towards  develop- 
ing a  practical  examination  than  has  any  state  board;  and  their  written  tests  are 
probably  also  more  severe;  with  the  result  that  between  the  years  1900  and  1909, 
46  per  cent  of  graduated  doctors  applying  for  the  naval  medical  corps  failed;  between 
1904  and  1909,  81  per  cent  of  the  applicants  for  the  Marine  Hospital  service  failed; 
and  out  of  1512  candidates  for  the  army  medical  corps  between  1888  and  1909, 
72  per  cent  failed:1  this,  although  very  few  of  the  applicants  examined  came  from 
the  unmitigatedly  bad  schools. 

To  do  their  duty  fiilly,  the  state  boards  require  to  be  properly  constituted,  orga- 
nized, and  equipped.  At  present  none  of  them  fulfils  all  these  conditions.  In  conse- 
quence it  is  difficult  to  know  where  to  lodge  responsibility.  In  some  states  the  law 
is  BO  weak  that  a  board  can  be  successfully  "mandamused"  the  moment  it  raises  a 
finger.  Elsewhere,  a  good  law  is  practically  negatived  by  the  inactivity,  if  not  worse, 
of  a  board  that  excuses  itself  by  the  apathy  of  the  public  or  by  the  "  pull "  of  the  medi- 
cal schools.  In  general  the  boards  have  not  been  strongly  constituted.  In  many  states 
appointments  are  regarded  as  political  spoils;  quite  generally  teachers  are  ineligible 
for  appointment.  It  happens,  therefore,  that  the  boards  are  sometimes  weak,  and 
either  unwilling  to  antagonize  the  schools  or  legally  incapable  of  so  doing;  again, 
well  meaning  but  incompetent;  in  some  cases  unquestionably  neither  weak  nor  well 

1  For  the  records  upon  which  these  statements  are  based,  acknowledgments  are  due  to  the  Surgeon- 
General  of  the  Navy,  the  Surgeon-General  of  the  Marine  Hospital  Service,  and  to  the  Surgeon-Gen- 
eral of  the  Army,  respectively. 


THE  STATE  BOARDS  171 

meaning,  but  cunning,  powerful,  and  closely  aligned  with  selfish  and  harmful  politi- 
cal interests.  In  a  few  instances,  that  stand  out,  the  boards  are  vigorous,  intelligent, 
and  public  spirited, —  notably  in  Colorado,  Michigan,  and  Minnesota. 

In  the  matter  of  organization  they  are  decidedly  defective.  The  whole  weight  rests 
usually  upon  a  single  executive  officer,  the  secretary,  whose  sole  staff  consists  of  a 
stenographer,  if  that.  As  long  as  everything  depends  on  the  personality  of  a  single 
individual,  administration  will  be  liable  to  marked  fluctuations.  There  can  be  neither 
security  nor  continuity.  For  enlightened  public  opinion  and  accepted  ideals  have  not 
as  yet  established  definite  and  correct  policy.  Organization  would  within  limits  be 
independent  of  individuals ;  for  it  embodies  a  routine  that  fortifies  every  gain  won, 
and  makes  possible  the  division  of  labor  that  is  indispensable  to  system  and  thor- 
oughness. 

A  bureau  properly  organized  cannot  live  on  small  fees.  It  requires  liberal  support ; 
for  it  must  be  in  position  to  take  trouble  to  secure  information  and  to  defend  its 
rights.  The  power  that  validates  the  diploma  with  its  license  must  have  the  strength 
to  protect  its  issues  against  either  debasement  or  infringement.  The  physician,  like 
the  lawyer,  is  an  agent  of  the  state.  If  he  proves  unworthy,  the  same  board  that 
vouched  for  him  must  have  power  to  recall  its  act ;  and  its  function  must  extend  to 
the  prosecution  of  fraudulent  or  unwarranted  attempts  to  practise  without  its  official 
sanction.  Any  effort  to  exercise  powers  of  recall  or  restraint  will  of  course  be  resisted. 
The  state  must  therefore  provide  funds  that  will  enable  the  board  to  defend  its  action 
in  the  courts. 

A  model  state  board  law  must  therefore  guard  the  following  points:  the  member- 
ship of  the  board  must  be  drawn  from  the  best  elements  of  the  profession,  including 
— not,  as  now,  prohibiting — those  engaged  in  teaching;  the  board  must  be  armed 
with  the  authority  and  machinery  to  institute  practical  examinations,  to  refuse 
recognition  to  unfit  schools,  and  to  insist  upon  such  preliminary  educational  stand- 
ards as  the  state's  own  educational  system  warrants ;  finally,  it  must  be  provided  either 
by  appropriation  or  by  greatly  increased  fees  with  funds  adequate  to  .perform  effi- 
ciently the  functions  for  which  it  was  created.  The  additional  powers  needed  in  order 
to  deal  as  effectively  with  the  practice  of  medicine,  lie  outside  the  present  discussion. 

Far-reaching  legislative  changes  would  be  required  in  most  states  before  the  state 
boards  could  play  the  part  here  assigned  to  them.  Yet  for  it  they  are  clearly  des- 
tined. As  a  matter  of  fact,  recent  legislation  has  been  self-contradictory.  The  boards 
have  been  strengthened,  their  powers  more  satisfactorily  defined ;  and  thereupon  the 
end  thus  sought  has  been  partially  defeated  by  the  creation  of  sectarian  boards  with 
lower  standards  and  looser  ideas.  Minnesota,  for  example,  obtained  an  excellent 
law,  consolidated  the  medical  schools  of  the  state,  established  a  high  standard,  and 
quarantined  against  invasion  by  a  low-grade  product  from  without ;  and  then,  having 
fairly  secured  for  the  people  of  the  state  the  best  attainable  conditions  in  the  mat- 
ter of  protecting  the  public  health,  it  proceeded  partly  to  undo  the  good  work  by  es- 


172  MEDICAL  EDUCATION 

tablishing  a  separate  osteopathic  board  with  power  to  license  osteopaths  —  who  will 
treat  all  diseases,  and  quite  possibly  in  all  sorts  of  ways  —  according  to  standards 
and  methods  fundamentally  at  variance  with  the  main  statute  already  outlined.  The 
creation  of  separate  boards  is  thus  a  roundabout  method  of  recommitting  the  errors 
that  the  main  currents  of  scientific  thinking  and  effort  are  endeavoring  to  remedy. 
Our  forty-nine  states  and  territories  have  now  eighty-two  different  boards  of  medi- 
cal examiners.  The  province  of  the  state  in  this  matter  is  plain.  It  cannot  allow  one 
set  of  practitioners  to  exist  on  easier  and  lower  terms  than  another.  It  cannot  indeed 
be  a  party  to  scientific  or  sectarian  controversy.  But  it  can  and  must  safeguard  the  con- 
ditions upon  which  such  controversy  may  be  fought  to  its  finish.  The  mooted  points 
concern  only  therapeutics;  in  respect  to  all  else  there  is  complete  agreement.  If  matters 
in  dispute  are  omitted  from  the  examination,  enough  is  left  for  all  essential  pur- 
poses. A  single  board  should  subject  all  candidates,  of  whatever  school,  to  the  same 
tests  at  every  point.  The  license  of  the  state  is  a  guarantee  of  knowledge,  education, 
and  skill.  The  layman  is  in  no  position  to  make  allowances.  The  state's  M.D.  and 
the  state's  D.O.  offer  themselves  for  essentially  the  same  purposes.  The  state  stands 
equally  as  guarantor  of  both.  No  citizen  can  indeed  be  wholly  protected  by  the  state 
against  his  own  ignorance,  fanaticism,  or  folly.  A  man  who  does  not  "believe"  in 
doctors  cannot  be  forced  to  call  them  in  or  to  heed  them,  any  more  than  a  man  who 
does  not  "believe"  in  wearing  rubbers  can  be  compelled  to  don  them  in  slushy 
weather.  The  state  is  powerless  there.  But  having  undertaken  to  vise  practising  physi- 
cians for  the  protection  of  those  who  summon  them,  it  must  see  to  it  that  the 
licenses  to  which  it  gives  currency  bear  a  fairly  uniform  value.  Between  the  graduate  of 
Harvard  and  the  graduate  of  the  Boston  College  of  Physicians  and  Surgeons,  the 
layman  could  not  judge  even  if  he  knew  the  origin  of  each;  as  a  matter  of  fact,  he 
rarely  knows  so  much.  But  in  the  act  of  licensing  both  for  one  purpose,  the  state 
assures  its  citizens  of  their  substantial  equality.  It  is  shocking  to  reflect  that,  what 
with  written  examinations  and  separate  boards,  the  divergencies  run  all  the  way  from 
a  high  degree  of  competency  to  utter  ignorance  and  unfitness. 

There  is  no  question  that  in  the  end  the  medical  sects  will  disappear.  The  dissenter 
cannot  live  on  high  entrance  and  educational  standards.  Pending  his  disappearance, 
the  combination  board  is  the  least  of  the  evils  to  which  we  are  liable.  The  terms  upon 
which  these  boards  are  now  obtainable  throw  a  strong  light  on  the  backward  state  of 
public  opinion.  In  New  York  state,  homeopaths,  eclectics,  and  osteopaths,  making 
together  but  a  negligible  proportion  of  the  practising  physicians  of  the  state,  have 
together  a  majority  on  the  state  examining  board. 

Under  existing  conditions,  though  the  state  boards  might  well  be  constituted  on 
a  uniform  plan  and  with  the  same  powers,  a  certain  degree  of  diversity  is  unavoid- 
able; but  a  certain  degree  of  inevitable  diversity  is  no  excuse  for  hopeless  confusion. 
The  variations  now  found  both  in  the  laws  and  in  their  administration  are  fairly 
chaotic.  In  one  state  the  board  can  and  does  fix  entrance  requirements;  in  the  next 


THE  STATE  BOARDS  173 

it  can,  but  does  not;  in  a  third  it  neither  does  nor  can.  Six  boards1  have  announced 
the  requirement  of  one  or  more  years  of  college  work  preliminary  to  medical  school- 
ing as  the  basis  of  practice  in  their  respective  states;  but  seventy-six  remain  to  be 
converted.  Their  conversion,  with  the  necessary  changes  in  the  state  laws,  must  pre- 
cede the  actual  elevation  of  the  entire  medical  profession.  For  though  agreed  eleva- 
tion of  standard  by  individual  schools  improves  their  own  product  and  indirectly 
leavens  the  mass,  it  does  not  stop  the  making  of  low-grade  doctors.  Temporarily  it 
even  assists  the  low-grade  school.  The  ultimate  improvement  of  the  entire  mass  will 
come  from  control  of  all  schools  through  the  state  boards,  and  not  merely  from  vol- 
untary action  on  the  part  of  the  more  self-respecting  institutions.  The  middle  west 
seems  likely — the  osteopaths  permitting — first  to  realize  this  condition;  for  the 
states  will  surely  not  leave  the  practice  of  medicine  within  their  borders  open  to 
strangers  on  terms  denied  to  their  own  sons. 

Whether  or  not  it  will  be  left  for  the  osteopaths  to  say,  depends  just  now  on  mak- 
ing the  public  appreciate  the  fact  that  the  point  at  issue  is  not  a  matter  of  business. 
A  clever  hue  and  cry  has  been  raised  to  give  the  controversy  the  appearance  of  a 
competition  between  rival  claimants  for  business  patronage.  The  instinct  for  fair 
play,  opposition  to  exclusive  or  aristocratic  privileges,  have  thus  won  for  the  secta- 
rian a  chance  on  his  own  terms.  Unfortunately,  this  leaves  the  sick  man  wholly  out 
of  account.  Medicine,  curative  and  preventive,  has  indeed  no  analogy  with  business. 
Like  the  army,  the  police,  or  the  social  worker,  the  medical  profession  is  supported  for 
a  benign,  not  a  selfish,  for  a  protective,  not  an  exploiting,  purpose.  The  knell  of  the 
exploiting  doctor  has  been  sounded,  just  as  the  day  of  the  freebooter  and  the  soldier 
of  fortune  has  passed  away. 

Despite  imperfect  and  discordant  laws  and  inadequate  resources,  the  state  board 
has  abundantly  justified  itself.  It  is  indeed  hardly  more  than  quarter  of  a  century 
old ;  yet,  in  summing  up  the  forces  that  have  within  that  period  made  for  improved 
conditions,  the  state  boards  must  be  prominently  mentioned.  Their  role  is  likely  to 
be  increasingly  important.  They  have  developed  considerable  esprit  de  corps.  Their 
power  of  combined  action  on  broad  lines  has  distinctly  increased  even  in  the  last  few 
years.  Reciprocity  between  states  whose  laws  are  measurably  concordant  and  whose 
ideals  are  taking  similar  shape  tends  to  demonstrate  the  fundamental  sameness  of 
the  problems  requiring  solution.  Out  of  these  first  cooperative  efforts,  a  model  law 
will  emerge ;  federated  action  may  become  possible.  Perhaps  the  entire  country  may 
some  day  be  covered  by  a  national  organization  engaged  in  protecting  the  public 
health  against  the  formidable  combination  made  by  ignorance,  incompetency,  com- 
mercialism, and  disease. 


1  Minnesota,  North  Dakota,  South  Dakota,  Connecticut,  Colorado,  Kansas. 


CHAPTER  XII 

THE  POSTGRADUATE  SCHOOL 

THE  postgraduate  school  as  developed  in  the  United  States  may  be  characterized 
as  a  "compensatory  adjustment."  It  is  an  effort  to  mend  a  machine  that  was  pre- 
destined to  break  down.  Inevitably,  the  more  conscientious  and  intelligent  men 
trained  in  most  of  the  medical  schools  herein  described  must  become  aware  of  their 
unfitness  for  the  responsibilities  of  medical  practice;  the  postgraduate  school  was 
established  to  do  what  the  medical  school  had  failed  to  accomplish. 

"When  I  graduated  in  the  spring  of  1869,"  says  Dr.  John  A.  Wyeth,1  "I  can 
never  forget  the  sinking  feeling  that  came  over  me  when  I  realized  how  incompetent 
I  was  to  undertake  the  care  of  those  in  the  distress  of  sickness  or  accident.  A  week 
later,  after  arriving  in  my  native  village  in  Alabama,  I  rented  a  small  office  and  at- 
tached my  sign  to  the  front  door.  Within  two  months,  the  tacks  were  withdrawn  by 
the  hand  which  had  placed  them  there  and  the  sign  was  stowed  away  in  the  bottom  of 
my  trunk.  Two  months  of  hopeless  struggle  with  a  Presbyterian  conscience  had  con- 
vinced me  that  I  was  not  fit  to  practise  medicine,  and  that  nothing  was  left  for  me 
but  to  go  out  into  the  world  of  business  to  earn  money  enough  to  complete  my  edu- 
cation. I  felt  the  absolute  need  of  clinical  experience,  and  a  conviction,  which  then 
forced  itself  upon  my  mind,  that  no  graduate  in  medicine  was  competent  to  practise 
until  he  had  had,  in  addition  to  his  theoretical,  a  clinical  and  laboratory  training,  was 
the  controlling  idea  in  my  mind  when,  in  later  years  the  opportunity  offered,  it  fell 
to  my  good  fortune  to  establish  in  this  city  the  New  York  Polyclinic  Medical  School 
and  Hospital." 

The  postgraduate  school  was  thus  originally  an  undergraduate  repair  shop.  Its 
instruction  was  necessarily  at  once  elementary  and  practical.  There  was  no  time  to 
go  back  to  fundamentals;  it  was  too  late  to  raise  the  question  of  preliminary  edu- 
cational competency.  Urgency  required  that  in  the  shortest  possible  time  the  young 
physician  already  involved  in  responsibility  should  acquire  the  practical  technique 
which  the  medical  school  had  failed  to  impart.  The  courses  were  made  short,  fre- 
quently covering  less  than  a  month ;  and  they  aimed  preeminently  to  teach  the  young 
doctor  what  to  "  do "  in  the  various  emergencies  of  general  practice. 

As  the  general  level  of  medical  education  has  risen,  the  function  of  these  insti- 
tutions has  been  somewhat  modified.  The  general  course,  aiming  to  make  good  de- 
ficiencies at  large,  has  tended  to  give  way  to  special  courses  adapted  to  the  needs  of 
those  inclined  to  devote  themselves  more  or  less  exclusively  to  some  particular  line 
of  work.  Simultaneously,  as  the  facilities  of  the  schools  have  enlarged,  they  have  be- 
come centers  to  which  at  intervals  men  practising  in  isolated  places  may  return  for 

1  Proceedingt  of  the  Nineteenth  Annual  Meeting  of  the  Atsociation  of  American  Medical  CoUeget, 
pp.  25,  26  (abridged). 


THE  POSTGRADUATE  SCHOOL  175 

brief  periods  in  order  to  catch  up  with  the  times.  Once  more  the  training  offered  is 
of  a  practical,  not  of  a  fundamental  or  intensive,  kind.  It  is  calculated  to  "teach  the 
trick" — or,  perhaps  better,  to  exhibit  an  instructor  in  the  act  of  doing  it.  For,  as 
nothing  is  known  of  individuals  in  the  stream  of  students  who  course  through  the 
schools,  it  is  impossible  to  give  them  an  active  share  in  the  work  that  goes  on  at  the 
bedside  or  in  the  operating-room.  Their  part  is  mainly  passive ;  they  look  on  at  expert 
diagnosticians  or  operators.  The  danger  of  permitting  an  unknown  student,  tarrying 
for  a  brief  stay,  to  participate  at  close  range  is  prohibitive.  In  surgery  the  so-called 
practical  courses  are  not  usually  worked  out  in  such  fashion  that  cadaver  work,  animal 
work,  and  service  as  dresser  might  prepare  for  actual  participation  :  the  school  lacks 
means  and  facilities ;  the  students  lack  the  time.  In  medicine  the  absence  of  sufficient 
material,  the  lack  of  proper  hospital  organization  and  equipment,  the  scrappiness  of 
professional  service,  combine  to  prevent  a  systematic,  thorough,  and  intimate  discipline. 

Of  the  thirteen  postgraduate  schools,1  the  best  of  them  reflect  the  conditions  and 
purposes  above  described.  The  Postgraduate  and  Polyclinic  of  New  York  and  the 
Polyclinic  of  Philadelphia  command  large  dispensary  services  and  considerable  hos- 
pital clinics,  partly  in  their  own  hospitals,  partly  in  public  and  private  hospitals  in 
the  city.  No  unkind  criticism  is  intended  when  the  teaching  is  characterized  as  too 
immediately  practical  to  be  scientifically  stimulating:  it  has  the  air  of  handicraft, 
rather  than  science.  Comparatively  little  is  done  in  internal  medicine:  surgery  and 
the  specialties  predominate.  The  courses,  being  practical  and  definite,  are  discon- 
nected ;  the  faculties  are  huge  and  unorganized.  In  the  main,  demonstrative  instruc- 
tion is  offered  to  small  bodies  of  physicians,  who  come  and  go  uninterruptedly  through 
the  year.  Only  one  of  the  three  —  the  Philadelphia  school  —  has  a  laboratory  build- 
ing, and  in  that  no  advanced  work  is  in  progress ;  the  two  New  York  schools  have 
laboratory  space  or  equipment  adequate  only  to  routine  clinical  examinations.  The 
teaching  is  in  the  main  more  elementary  than  the  upper  class  instruction  of  a  good 
undergraduate  school  of  medicine.  It  is,  of  course,  also  at  times  more  special  in 
character.  With  the  exception  of  the  New  York  Postgraduate,  these  schools  are  with- 
out endowment:  they  live  on  fees,  donations,  and  hospital  receipts. 

Two  departmental  postgraduate  schools  are  conducted  by  the  government  at 
Washington  for  those  accepted  for  service  in  the  army  or  navy  medical  corps.  Eligible 
for  these  appointments  are  graduated  physicians  who  have  had  a  year  of  hospital 
experience  or  three  years  of  practice.  Excellent  practical  instruction  is  furnished  by 
way  of  supplementing  the  usual  undergraduate  course.  The  needs  of  the  services  can 

1  Four  are  situated  in  Greater  New  York :  (1)  The  New  York  Polyclinic  Medical  School,  (2)  New  York 
Postgraduate  Medical  School,  (3)  Brooklyn  Postgraduate  Medical  School,  (4)  Manhattan  Eye,  Ear, 
and  Throat  Postgraduate  School ;  four  in  Chicago :  (5)  Postgraduate  Medical  School,  (6)  The  Chicago 
Polyclinic,  (7)  Illinois  Postgraduate  Medical  School,  (8}  Chicago  Ear,  Eye,  Nose,  and  Throat  College; 
one  each  in  Philadelphia,  (9)  The  Philadelphia  Polyclinic;  Kansas  City,  (10)  Postgraduate  Medical 
School;  New  Orleans,  (11)  New  Orleans  Polyclinic  (affiliated  with  Tulane  University);  and  two  in 
Washington,  (12)  Array  Medical  School,  (13)  Navy  Medical  School.  A  number  of  schools  offer  special 
courses  to  graduates,  in  special  summer  and  regular  winter  sessions. 


176  MEDICAL  EDUCATION 

be  very  definitely  formulated ;  the  course  worked  out  aims  to  meet  them.  The  ac- 
cepted surgeons  get  in  this  way  a  concentrated  practical  drill  in  bacteriology,  hygiene, 
and  military  surgery.  The  laboratories  are  excellently  equipped,  though  cramped 
for  space.  The  army  school  enjoys  the  advantage  of  contact  with  the  great  library  and 
museum  of  the  surgeon-general's  office.  The  schools,  as  yet  in  their  infancy,  may  not 
improbably  develop  into  research  laboratories  dealing  with  the  specific  problems  that 
crop  up  in  naval  and  military  service  in  various  quarters  of  the  globe. 

Postgraduate,  like  other  schools,  vary  in  character.  We  have  spoken  of  the  best. 
The  others  are  weak  concerns  wearing  a  commercial  hue.  The  Brooklyn  Postgraduate 
School,  for  instance,  entertains  less  than  half  a  dozen  students  on  the  average  at 
a  time,  in  a  wretched  hospital,  really  a  death-trap,  heavily  laden  with  debt,  and 
without  laboratory  equipment  enough  to  make  an  ordinary  clinical  examination ;  the 
Kansas  City  affair  had,  when  visited,  no  students  in  its  improvised  hospital  contain- 
ing 25  ward  beds,  only  13  of  them  occupied ;  it  ekes  out  its  opportunities  with  clinics 
at  the  public  hospital.  Chicago,  varied  and  picturesque  in  this  as  in  all  else  pertain- 
ing to  medical  education,  supports  four  postgraduate  institutions.  None  of  them  has 
a  satisfactory  plant.  All  are  stock  companies.  Only  unmistakable  scientific  activity 
could  dislodge  the  unpleasant  suspicion  of  commercial  motive  thus  suggested.  No  such 
activity  is  in  any  of  them  observable.  A  cynical  candor  admits  in  one  place  that  "it 
pays  the  teachers  through  referred  cases ; "  in  another,  "  it  establishes  the  reputation 
of  a  man  to  teach  in  a  postgraduate  school ; "  in  a  third,  "  it  pays  through  advertising 
teachers."  In  one  a  youth  was  observed  working  with  a  microscope.  Inquiry  elicited 
the  fact  that  he  was  the  teacher  of  clinical  laboratory  technique,  lecturing  in  the 
absence  of  the  "professor."  The  following  dialogue  took  place: 

"  Are  you  a  doctor  ?  " 

"No." 

"  A  student  of  medicine  ?  " 

"Yes." 

"Where?" 

"  At  the  Jenner  Night  School" 

"  In  what  year  ?  " 

"The  first" 

A  first-year  student  of  medicine  in  a  night  school  was  thus  laboratory  instructor  and 
pro  tempore  lecturing  professor  in  clinical  microscopy  in  the  Chicago  Polyclinic. 

Improved  medical  education  will  undoubtedly  cut  the  ground  from  under  the  in- 
dependent postgraduate  school  as  we  know  it.  This  is  not  to  say  that  the  undergrad- 
uate medical  curriculum  will  exhaust  the  field.  On  the  contrary,  the  undergraduate 
school  will  do  only  the  elementary  work ;  but  that  it  will  do,  not  needing  subsequent 
and  more  elementary  instruction  to  patch  it  up.  Graduate  instruction  will  be  advanced 
and  intensive, — the  natural  prolongation  of  the  elective  courses  now  coming  into 
vogue.  For  productive  investigation  and  intensive  instruction,  the  medical  school  will 


THE  POSTGRADUATE  SCHOOL  177 

use  its  own  teaching  hospital  and  laboratories;  for  the  elaboration  of  really  thorough 
training  in  specialties  resting  on  a  solid  undergraduate  education,  it  may  use  the 
great  municipal  hospitals  of  the  larger  cities.  But  advanced  instruction  along  these 
lines  will  not  thrive  in  isolation.  It  will  be  but  the  upper  story  of  a  university  de- 
partment of  medicine.  The  postgraduate  schools  of  the  better  type  can  hasten  this 
evolution  by  incorporating  themselves  in  accessible  universities,  taking  up  univer- 
sity ideals,  and  submitting  to  reorganization  on  university  lines. 


CHAPTER  XIII 

THE  MEDICAL  EDUCATION  OF  WOMEN 

MEDICAL  education  is  now,  in  the  United  States  and  Canada,  open  to  women  upon 
practically  the  same  terms  as  men.  If  all  institutions  do  not  receive  women,  so  many 
do,  that  no  woman  desiring  an  education  in  medicine  is  under  any  disability  in  find- 
ing a  school  to  which  she  may  gain  admittance.  Her  choice  is  free  and  varied.  She  will 
find  schools  of  every  grade  accessible :  the  Johns  Hopkins,  if  she  has  an  academic 
degree;  Cornell,  if  she  has  three-fourths  of  one;  Rush  and  the  state  universities,  if 
she  prefers  the  combined  six  years'  course;  Toronto  on  the  basis  of  a  high  school 
education;  Meridian,  Mississippi,  if  she  has  had  no  definable  education  at  all. 

Woman  has  so  apparent  a  function  in  certain  medical  specialties  and  seemingly  so 
assured  a  place  in  general  medicine  under  some  obvious  limitations  that  the  struggle 
for  wider  educational  opportunities  for  the  sex  was  predestined  to  an  early  success  in 
medicine.  It  is  singular  to  observe  the  use  to  which  the  victory  has  been  put.  The 
following  tables  show  recent  developments  in  coeducational  and  in  women's  medical 
schools  taken  separately: 

Number  of  Coeducational  Number  of  Number  of 

Year  Medical  School*  Women  Students                Women  Graduates 

1904  97  946  198 

1905  96  852  165 

1906  90  706  200 

1907  86  718  172 

1908  88  649  139 

1909  91  752  129 

Women's  Number  of  Number  of 

Year  Medical  Schools  Students  Graduates 

1904  3  183  56 

1905  3  221  54 

1906  3  189  33 

1907  3  210  39 

1908  3  186  46 

1909  3  169  33 

COMBINED 

Number  of  Number  of  Number  of 

Year  Schools  Women  Students  Women  Graduates 

1904  100  1129  254 

1905  99  1073  219 

1906  93  895  233 

1907  89  928  211 

1908  91  835  185 

1909  94  921  162 

Now  that  women  are  freely  admitted  to  the  medical  profession,  it  is  clear  that 
they  show  a  decreasing  inclination  to  enter  it.  More  schools  in  all  sections  are  open 
to  them ;  fewer  attend  and  fewer  graduate.  True  enough,  medical  schools  generally 
have  shrunk ;  but  as  the  opportunities  of  women  have  increased,  not  decreased,  and 
within  a  period  during  which  entrance  requirements  have,  so  far  as  they  are  con- 


MEDICAL  EDUCATION  OF  WOMEN  179 

cerned,  not  materially  altered,  their  enrolment  should  have  augmented,  if  there  is 
any  strong  demand  for  women  physicians  or  any  strong  ungratified  desire  on  the  part 
of  women  to  enter  the  profession.  One  or  the  other  of  these  conditions  is  lacking, — 
perhaps  both. 

Whether  it  is  either  wise  or  necessary  to  endow  separate  medical  schools  for 
women  is  a  problem  on  which  the  figures  used  throw  light.  In  the  first  place,  eighty 
per  cent  of  women  who  have  in  the  last  six  years  studied  medicine  have  attended 
coeducational  institutions.  None  of  the  three  women^s  medical  colleges  now  existing 
can  be  sufficiently  strengthened  without  an  enormous  outlay.  The  motives  which 
elsewhere  recommend  separation  of  the  sexes  would  appear  to  be  without  force,  all 
possible  allowance  being  made  for  the  special  and  somewhat  trying  conditions  in- 
volved. In  the  general  need  of  more  liberal  support  for  medical  schools,  it  would 
appear  that  large  sums,  as  far  as  specially  available  for  the  medical  education  of 
women,  would  accomplish  most  if  used  to  develop  coeducational  institutions,  in 
which  their  benefits  would  be  shared  by  men  without  loss  to  women  students;  but,  it 
must  be  added,  if  separate  medical  schools  and  hospitals  are  not  to  be  developed 
for  women,  interne  privileges  must  be  granted  to  women  graduates  on  the  same  terms 
as  to  men. 


CHAPTER  XIV 

THE  MEDICAL  EDUCATION  OF  THE  NEGRO 

THE  medical  care  of  the  negro  race  will  never  be  wholly  left  to  negro  physicians. 
Nevertheless,  if  the  negro  can  be  brought  to  feel  a  sharp  responsibility  for  the  physi- 
cal integrity  of  his  people,  the  outlook  for  their  mental  and  moral  improvement  will 
be  distinctly  brightened.  The  practice  of  the  negro  doctor  will  be  limited  to  his  own 
race,  which  in  its  turn  will  be  cared  for  better  by  good  negro  physicians  than  by  poor 
white  ones.  But  the  physical  well-being  of  the  negro  is  not  only  of  moment  to  the  negro 
himself.  Ten  million  of  them  live  in  close  contact  with  sixty  million  whites.  Not  only 
does  the  negro  himself  suffer  from  hookworm  and  tuberculosis;  he  communicates  them 
to  his  white  neighbors,  precisely  as  the  ignorant  and  unfortunate  white  contaminates 
him.  Self-protection  not  less  than  humanity  offers  weighty  counsel  in  this  matter ; 
self-interest  seconds  philanthropy.  The  negro  must  be  educated  not  only  for  his  sake, 
but  for  ours.  He  is,  as  far  as  human  eye  can  see,  a  permanent  factor  in  the  nation. 
He  has  his  rights  and  due  and  value  as  an  individual ;  but  he  has,  besides,  the  tremen- 
dous importance  that  belongs  to  a  potential  source  of  infection  and  contagion. 

The  pioneer  work  in  educating  the  race  to  know  and  to  practise  fundamental 
hygienic  principles  must  be  done  largely  by  the  negro  doctor  and  the  negro  nurse. 
It  is  important  that  they  both  be  sensibly  and  effectively  trained  at  the  level  at 
which  their  services  are  now  important.  The  negro  is  perhaps  more  easily  "  taken  in  " 
than  the  white;  and  as  his  means  of  extricating  himself  from  a  blunder  are  limited, 
it  is  all  the  more  cruel  to  abuse  his  ignorance  through  any  sort  of  pretense.  A  well- 
taught  negro  sanitarian  will  be  immensely  useful ;  an  essentially  untrained  negro 
wearing  an  M.D.  degree  is  dangerous. 

Make-believe  in  the  matter  of  negro  medical  schools  is  therefore  intolerable. 
Even  good  intention  helps  but  little  to  change  their  aspect.  The  negro  needs  good 
schools  rather  than  many  schools, —  schools  to  which  the  more  promising  of  the  race 
can  be  sent  to  receive  a  substantial  education  in  which  hygiene  rather  than  surgery, 
for  example,  is  strongly  accentuated.  If  at  the  same  time  these  men  can  be  imbued 
with  the  missionary  spirit  so  that  they  will  look  upon  the  diploma  as  a  commission 
to  serve  their  people  humbly  and  devotedly,  they  may  play  an  important  part  in  the 
sanitation  and  civilization  of  the  whole  nation.  Their  duty  calls  them  away  from 
large  cities  to  the  village  and  the  plantation,  upon  which  light  has  hardly  as  yet 
begun  to  break. 

Of  the  seven  medical  schools  for  negroes  in  the  United  States,1  five  are  at  this  mo- 
ment in  no  position  to  make  any  contribution  of  value  to  the  solution  of  the  problem 

'Washington,  D.C.:  Howard  University;  New  Orleans:  Flint  Medical  College;  Raleigh  (N.C.): 
Leonard  Medical  School ;  Knoxville :  Knoxville  Medical  College ;  Memphis  :  Medical  Department  of 
the  University  of  West  Tennessee ;  Nashville :  Meharry  Medical  College ;  Louisville :  National  Med- 
ical College. 


MEDICAL  EDUCATION  OF  THE  NEGRO  181 

above  pointed  out ;  Flint  at  New  Orleans,  Leonard  at  Raleigh,  the  Knoxville,  Mem- 
phis, and  Louisville  schools  are  ineffectual.  They  are  wasting  small  sums  annually 
and  sending  out  undisciplined  men,  whose  lack  of  real  training  is  covered  up  by  the 
imposing  M.D.  degree. 

Meharry  at  Nashville  and  Howard  at  Washington  are  worth  developing,  and 
until  considerably  increased  benefactions  are  available,  effort  will  wisely  concentrate 
upon  them.  The  future  of  Howard  is  assured ;  indeed,  the  new  Freedman's  Hospital 
is  an  asset  the  like  of  which  is  in  this  country  extremely  rare.  It  is  greatly  to  be 
hoped  that  the  government  may  display  a  liberal  and  progressive  spirit  in  adapting 
the  administration  of  this  institution  to  the  requirements  of  medical  education. 

Meharry  is  the  creation  of  one  man,  Dr.  George  W.  Hubbard,  who,  sent  to  the 
south  at  the  close  of  the  war  on  an  errand  of  mercy,  has  for  a  half-century  devoted 
himself  singly  to  the  elevation  of  the  negro.  The  slender  resources  at  his  command 
have  been  carefully  husbanded  ;  his  pupils  have  in  their  turn  remembered  their  obli- 
gations to  him  and  to  their  school.  The  income  of  the  institution  has  been  utilized 
to  build  it  up.  The  school  laboratories  are  highly  creditable  to  the  energy  and  in- 
telligence of  Dr.  Hubbard  and  his  assistants.  The  urgent  need  is  for  improved  clin- 
ical facilities  —  a  hospital  building  and  a  well  equipped  dispensary.  Efforts  now 
making  to  acquire  them  deserve  liberal  support. 

The  upbuilding  of  Howard  and  Meharry  will  profit  the  nation  much  more  than 
the  inadequate  maintenance  of  a  larger  number  of  schools.  They  are,  of  course, 
unequal  to  the  need  and  the  opportunity;  but  nothing  will  be  gained  by  way  of 
satisfying  the  need  or  of  rising  to  the  opportunity  through  the  survival  of  feeble,  ill 
equipped  institutions,  quite  regardless  of  the  spirit  which  animates  the  promoters. 
The  subventions  of  religious  and  philanthropic  societies  and  of  individuals  can  be 
made  effective  only  if  concentrated.  They  must  become  immensely  greater  before 
they  can  be  safely  dispersed. 


PART  II 

MEDICAL  SCHOOLS  OF  THE  UNITED  STATES 
AND  CANADA 

ARRANGED  ALPHABETICALLY  BY  STATES  AND  PROVINCES 
AND  SEPARATELY  CHARACTERIZED 

NOTE  :  Facts  given  are  at  of  date  when  the  school  wot  visited,  which 
is  specified  in  each  case. 

The  estimates  of  population  have,  with  the  few  exceptions  noted, 
been  kindly  made  by  the  Director  of  the  Census,  through  the  courtesy 
of  the  Secretary  of  Commerce  and  Labor. 


MEDICAL  SCHOOLS 
OF  THE  UNITED  STATES  AND  CANADA 

ALPHABETICALLY  ARRANGED  BY  STATES  AND  PROVINCES 

ALABAMA 

Population,  2,112,465.  Number  of  physicians,  2287.  Ratio,  1:  924. 
Number  of  medical  schools,  2. 

BIRMINGHAM:  Population,  55,945. 

BIRMINGHAM  MEDICAL  COLLEGE.  Organized  1894.  A  stock  company,  paying  annual 
dividends  of  6  per  cent. 

Entrance  requirement:  Nominal. 

Attendance:  185,  of  whom  168  are  from  Alabama. 

Teaching  staff:  32,  18  being  professors,  none  of  them  whole-time  teachers. 

Resources  available  for  maintenance:  Fees,  amounting  to  $14,550  (estimated). 

Laboratory  facilities:  The  teaching  of  anatomy,  for  which  there  is  abundant  ma- 
terial, is  limited  to  dissecting  on  old-fashioned  lines;  there  is  the  usual  chemical 
laboratory  and  a  small  outfit  for  instruction  in  bacteriology  and  pathology ;  the  ma- 
terial used  for  the  latter  is  purchased  in  the  east,  not  obtained  from  autopsies  or 
clinics.  No  animals  are  provided  for  experimental  purpose  beyond  the  use  of  dogs 
for  surgical  work.  There  are  no  physiological,  pharmacological,  or  clinical  labora- 
tories. The  building  is  poorly  kept,  and  there  is  neither  library  nor  museum. 

Clinical  facilities:  The  school  adjoins  the  Hillman  Hospital,  98  beds,  of  which  the 
faculty  has  charge  during  term  time.  Bedside  clinics  are  held,  but  the  students 
make  no  blood  or  urine  examinations;  obstetrical  cases  are  rare;  the  hospital  is 
largely  given  over  to  surgical  patients, — gunshot  and  other  wounds  being  decid- 
edly abundant. 

The  dispensary  service  is  as  yet  unorganized. 

Date  of  visit:  January,  1909. 

MOBILE:  Population,  56,335. 

MEDICAL  DEPARTMENT  OF  THE  UNIVERSITY  OF  ALABAMA.  Established  1859.  Now  an 
organic  department  of  the  state  university,  with  which,  however,  its  connection  is 
legal  only.  The  two  institutions  are  at  opposite  ends  of  the  state,  so  that  the 
medical  department  is  practically  a  local  school. 

Entrance  requirement:  Less  than  three-year  high  school  education. 


186  MEDICAL  EDUCATION 

Attendance:  204. 

Teaching  staff:  25,  of  whom  8  are  professors.  No  one  devotes  full  time  to  medical 
instruction. 

Resources  available  for  maintenance :  The  school  receives  from  the  state  an  annual  ap- 
propriation of  $5000,  in  return  for  which,  however,  sixty-seven  free  scholarships 
are  given,  one  to  each  county ;  the  school  is  therefore  in  effect  wholly  dependent  on 
tuition  fees,  amounting  to  $17,300,  for  its  support,  most  of  which  is  paid  out  in 
salaries. 

Laboratory  facilities :  The  laboratory  equipment  is  practically  limited  to  inorganic 
chemistry,  elementary  bacteriology  and  pathology,  and  anatomy,  taught  by  dis- 
secting first  the  goat,  then  the  human  cadaver.  The  school  occupies  a  well  kept 
old-fashioned  building,  recently  remodeled.  It  possesses  a  few  old  books,  but  no 
funds  with  which  to  add  to  them ;  and  a  small  museum,  mostly  composed  of  an- 
tiquated wax  or  papier-mache  models. 

Clinical  facilities:  For  clinical  instruction  the  school  has  access  to  the  Sisters'  Hos- 
pital, 100  beds,  the  faculty  being  the  staff  in  term  time.  The  senior  students  make 
blood  and  urine  examinations  in  connection  with  clinical  cases. 

Connected  with  the  college  building  is  a  new,  well  arranged  dispensary,  for  the 
conduct  of  which  an  appropriation  of  $50  a  month  is  available. 

DaU  ofvitit:  January,  1909. 

General  Considerations 

THE  foregoing  account  makes  it  clear  that  really  satisfactory  medical  education 
is  not  now  to  be  had  in  Alabama.  The  entrance  standards  are  low;  the  schools  are 
inadequately  equipped;  and  they  are  without  proper  financial  resources.  To  get 
together  their  present  numbers,  standards  must  be  kept  low;  in  consequence,  the 
medical  schools  do  nothing  to  promote  or  to  share  the  secondary  school  development 
of  the  state.  To  that  and  to  any  higher  movement  they  are  likely  to  be  obstacles. 
Neither  Alabama  nor  the  rest  of  the  south  actually  needs  either  school  at  this  time ; 
but  as  the  state  has  become  a  patron  of  medical  education,  it  will  hardly  retire  from 
the  field.  Under  these  circumstances,  its  policy  should  aim  to  bring  about  a  genuine 
and  effective  connection  between  the  medical  department  and  the  rest  of  the  state 
university.  The  task  of  elevating  entrance  standards  in  the  medical  department  and 
of  furnishing  a  higher  quality  of  scientific  training  would  probably  be  assisted  for  the 
time  being  by  removing  the  instruction  in  the  first  and  second  years  to  the  university 
itself  at  Tuscaloosa;  for  in  no  other  way  can  whole-time  instructors  be  now  procured. 
An  improvement  in  the  quality  of  training  furnished  in  the  scientific  branches  will 
ultimately  compel  a  higher  quality  of  clinical  instruction.  It  is  difficult  to  see  how  the 
influence  or  control  of  the  university  can  in  any  event  be  made  effective  in  Mobile, 
232  miles  distant,  at  the  opposite  end  of  the  state,  and  in  a  hospital  in  whose  clinical 


ARKANSAS  187 

management  there  is  no  continuity.  Birmingham  is  much  closer,  being  only  56  miles 
distant,  and  promises  to  offer  a  larger  supply  of  clinical  material.  If,  therefore,  the 
state  is  able  to  look  at  the  question  on  its  own  merits,  without  regard  to  the  rival 
claims  of  competing  towns,  it  should  establish  a  practice  requirement  that  would 
automatically  suppress  proprietary  instruction.  For  the  present,  the  university  might 
offer  two  years'  work  at  Tuscaloosa,  reserving  to  a  more  propitious  time  the  entire 
question  of  organizing  under  effective  university  control  a  complete  medical  school 
at  Birmingham,  which  is  the  nearest  feasible  location.  As  the  state  now  contains  one 
physician  to  every  924  inhabitants,  the  restriction  or  suspension  of  clinical  teaching 
for  some  years  to  come  involves  no  danger  to  the  community. 


ARKANSAS 

Population,  1,476,582.  Number  of  physicians,  2535.  Ratio,  1 :  582. 
Number  of  medical  schools,  2. 

LITTLE  ROCK:  Population,  44,931. 

(1)  MEDICAL  DEPARTMENT,  UNIVERSITY  OF  ARKANSAS.  Organized  1879.  An  indepen- 
dent institution,  not  even  "affiliated"  with  the  state  university  whose  name  it  bears. 

Entrance  requirement:  Nominal. 

Attendance:  179,  81  per  cent  from  Arkansas. 

Teaching  staff:  35,  18  being  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $14,100  (estimated). 

Laboratory  facilities :  After  an  existence  of  thirty  years  without  any  laboratory  fa- 
cilities except  a  dissecting-room  and  a  laboratory  for  inorganic  chemistry,  a  frame 
building  has  recently  been  supplied  with  a  meager  equipment  for  the  teaching  of 
pathology  and  bacteriology.  The  session  was,  however,  already  well  started  and 
the  new  laboratory  not  yet  in  operation.  No  museum,  no  books,  charts,  models, 
etc.,  are  provided. 

Clinical  facilities:  Hardly  more  than  nominal.  The  school  adjoins  the  City  Hospital, 
with  a  capacity  of  30  beds.  Froin  this  hospital  patients  are  brought  into  the  amphi- 
theater of  the  school  building.  There  are  no  ward  visits.  The  students  see  no  con- 
tagious diseases;  obstetrical  work  is  precarious;  of  post-mortems  there  is  no  mention. 
There  is  a  small  dispensary,  of  whose  attendance  no  record  is  procurable. 

Date  ofvirit:  November,  1909. 

(2)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  1906.  An  independent  organi- 
zation, formed  by  men  not  in  the  older  school. 


188  MEDICAL  EDUCATION 

Entrance  requirement:  Nominal. 

Attendance:  81,  59  per  cent  from  Arkansas. 

Teaching  staff':  34,  25  being  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $6450  (estimated). 

Laboratory  facilities :  Separate,  recently  organized,  and  very  disorderly  laboratories 
for  pathology,  bacteriology,  and  chemistry,  which  with  pharmacy  work  are  all  in 
charge  of  a  single  teacher,  who  is  also  pathologist  to  the  County  Hospital,  three 
miles  off.  He  proposes  shortly  to  add  physiology.  The  usual  wretched  dissecting- 
room  is  also  provided.  None  of  the  necessary  illustrative  paraphernalia  are  at  hand 
in  the  shape  of  books,  charts,  museum,  etc. 

Clinical  facilities:  The  faculty  of  the  school  controls  an  adjoining  hospital,  from 
which  patients  are  brought  into  the  amphitheater  for  demonstration  or  operation. 
At  operations  it  is  claimed  that  students  assist.  No  ward  rounds  are  made.  Occa- 
sional clinics  are  also  held  at  two  distant  hospitals  (county  and  penitentiary). 
Obstetrical  and  acute  medical  cases  are  rare;  contagious  diseases  are  not  seen. 
There  are  no  post-mortems.  A  small  daily  dispensary  attendance  is  claimed.  There 
is  no  adequate  dispensary  equipment. 

Dot*  of  visit :  November,  1909. 

General  Considerations 

BOTH  the  Arkansas  schools  are  local  institutions  in  a  state  that  has  at  this  date 
three  times  as  many  doctors  as  it  needs;  neither  has  a  single  redeeming  feature.  It  is 
incredible  that  the  state  university  should  permit  its  name  to  shelter  one  of  them. 
The  general  educational  interests  of  the  state  require  that  the  state  university,  now 
inconveniently  located  at  Fayetteville,  should  be  moved  to  Little  Rock.  Once  there, 
it  could  probably  get  possession  of  both  schools  and  organize  something  better  than 
either,  which  it  could  improve  as  its  resources  increase  with  the  general  prosperity 
of  the  state. 

CALIFORNIA1 

Population,  1,729,543.  Number  of  physicians  (exclusive  of  osteopaths),  4313.  Ratio, 

1:401. 
Number  of  medical  schools,  10. 

LOS  ANGELES:  Population,  116,420. 

(1)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Established  1903  as  an  independent 

1The  Director  of  the  Census  states:  "The  cities  of  Los  Angeles,  Oakland,  Berkeley,  and  San  Fran- 
cisco have  had  such  an  exceptionally  rapid  increase  that  no  estimates  of  their  population  have  been 
prepared."  The  figures  given  are  taken  from  the  census  of  1900. 


CALIFORNIA  189 

school,  it  suddenly  became,  in  1909,  nominally  the  medical  department  of  the 
University  of  Southern  California,  when  the  former  medical  department  of  that 
institution  cut  loose  in  order  to  become  the  Los  Angeles  clinical  department  of 
the  University  of  California.  The  seriousness  with  which  the  University  of  South- 
ern California  treats  medical  education  may  be  gathered  from  this  amusing 
performance. 

Entrance  requirement:  High  school  graduation  or  "equivalent."" 
Attendance:  2%. 

Teaching  staff":  41,  28  being  professors.  The  teachers  are  practising  physicians;  no 
one  gives  his  entire  time  to  the  school. 

Resources  available  for  maintenance:  Fees,  amounting  to  $4075  (estimated). 

Laboratory  facilities :  The  school  is  ordinary  in  type.  It  possesses  a  small  chemical 
laboratory,  a  single  laboratory  in  common  for  pathology,  histology,  and  bacteri- 
ology, with  meager  equipment  and  supplies,  and  no  animals;  a  dissecting-room 
with  sufficient  anatomical  material,  and  clay  for  modeling  bones ;  a  limited  num- 
ber of  wet  specimens,  and  a  small  number  of  books  in  a  room  that  is  locked,  though 
opened  to  students  on  request.  There  is  no  laboratory  for  physiology  or  pharma- 
cology. The  building  is  new,  attractive,  and  fairly  well  kept. 

Clinical  facilities :  A  considerable  part  of  one  floor  is  used  for  a  dispensary.  The 
rooms  are  poorly  equipped  and  cared  for;  there  is  no  clinical  laboratory.  The  at- 
tendance is  very  small,  for  the  neighborhood  is  decidedly  well-to-do. 

The  school  adjoins  a  private  hospital  in  which  many  of  the  teachers  are  inter- 
ested. It  is,  however,  of  no  teaching  use.  The  catalogue  describes  it  as  "not  a 
charity  hospital  by  any  means.  ...  In  fact  it  is  a  twentieth  century  classy  hospi- 
tal.'" For  clinical  instruction  the  students  have  access  to  the  County  Hospital,  sev- 
eral miles  distant,  where  the  school  has  the  use  of  100  beds,  holding  clinics  for 
senior  students  two  days  weekly.  In  surgery,  students  witness  an  operation  with- 
out taking  part  in  it;  in  medicine,  the  students  make  brief  histories,  which  are, 
however,  no  part  of  the  hospital  records.  Autopsies  are  done  by  the  internes,  who 
have  no  connection  with  the  medical  school.  Students  are  not  admitted  to  the  ob- 
stetrical ward.  Clinical  facilities  are  thus  extremely  limited,  for  the  management  of 
the  hospital  is  in  no  essential  respect  controlled  by  educational  considerations. 

Date  of  visit:  May,  1909. 

(2)  UNIVERSITY  OF  CALIFORNIA  :  CLINICAL  DEPARTMENT.  Up  to  March,  1909,  this 
school  offered  a  four-year  course  as  the  medical  department  of  the  University 
of  Southern  California ;  it  has  now  become  a  second  clinical  department  of  the 
University  of  California,  and  will  therefore  offer  after  June,  1910,  only  the  third 
and  fourth  years'  work.  See  (6). 


190  MEDICAL  EDUCATION 

Clinical  facilities :  Its  present  facilities  for  offering  the  instruction  of  the  last  two 
years  are,  for  a  university  department  on  a  two-year  college  basis,  distinctly 
meager.  It  enjoys  at  the  County  Hospital  the  same  facilities  as  the  local  College 
of  Physicians  and  Surgeons,  i.e.,  access  to  100  beds,  two  or  three  days  weekly 
being  devoted  to  clinics  for  the  senior  class.  Additional  opportunities,  depending 
on  the  personal  connections  of  members  of  the  faculty,  are  usually  of  slight  peda- 
gogic value.  The  school  has  an  excellent  dispensary  building,  fairly  equipped  in 
certain  respects,  but  indifferently  conducted,  though  the  attendance  is  good.  It 
is  also  in  close  proximity  to  a  good  medical  library.  The  clinical  teachers  are  all 
local  practitioners.  The  state  university  will  incur  no  expense  on  account  of  this 
department  for  two  years  at  least 

Date  ofvitit :  May,  1909. 

(3)  CALIFORNIA  MEDICAL  COLLEGE.  Eclectic.  Organized  at  Oakland  in  1879,  this 
school  has  led  a  roving  and  precarious  existence  in  the  meanwhile. 

Entrance  requirement:  Nominal. 

Attendance:  9,  of  whom  7  are  from  California. 

Teaching  staff":  27,  of  whom  26  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $1060  (estimated). 

Laboratory  facilities:  The  school  occupies  a  few  neglected  rooms  on  the  second  floor 
of  a  fifty-foot  frame  building.  Its  so-called  equipment  is  dirty  and  disorderly  be- 
yond description.  Its  outfit  in  anatomy  consists  of  a  small  box  of  bones  and  the 
dried-up  filthy  fragments  of  a  single  cadaver.  A  few  bottles  of  reagents  constitute 
the  chemical  laboratory.  A  cold  and  rusty  incubator,  a  single  microscope,  and  a 
few  unlabeled  wet  specimens,  etc.,  form  the  so-called  "equipment"  for  pathology 
and  bacteriology. 

Clinical  facilities :  There  is  no  dispensary  and  no  access  to  the  County  Hospital. 
The  school  is  a  disgrace  to  the  state  whose  laws  permit  its  existence. 

Datt  ofvitit:  May,  1909. 

(4)  Los  ANGELES  COLLEGE  OF  OSTEOPATHY.  Emigrated  from  Iowa  in  1905.  A  stock 
company. 

Entrance  requirement:  Less  than  an  ordinary  grammar  school  education,  with  con- 
ditions. Many  of  the  students  are  men  and  women  of  advanced  years. 

Attendance:  Began  two  years  ago  with  60,  now  claims  "more  than  250." 

Teaching  staff:  19.  All  the  teachers  are  practitioners. 

Resources  available  for  maintenance:  Fees,  the  annual  income  being  about  $37,500 


CALIFORNIA  191 

from  tuitions  and  a  considerable  sum  from  "treatments"  (see  below).  As  the  instruc- 
tion provided  is  inexpensive,  the  stock  must  be  a  very  profitable  investment. 

Laboratory  facilities :  The  school  occupies  a  five-story  building  containing  a  chemical 
laboratory,  with  meager  equipment  and  limited  desk  space,  and  a  single  labora- 
tory for  histology,  pathology,  and  bacteriology.  The  dissecting-room  contains 
five  tables,  but  sufficient  material.  The  rest  of  the  building  is  mainly  devoted  to 
treatment  rooms  and  the  business  office. 

Clinical  facilities:  There  is  no  free  dispensary.  Patients  who  are  willing  to  undergo 
treatment  before  a  class  pay  not  less  than  $3  a  month;  patients  who  are  treated 
in  the  presence  of  a  single  student  pay  $5.  A  hospital  is  now  under  construction. 

The  general  aspect  is  that  of  a  thriving  business.  An  abundance  of  advertising  mat- 
ter, in  which  the  profits  of  osteopathy  are  prominently  set  forth,1  is  distributed. 
Date  of  visit:  May,  1909. 

(5)  PACIFIC  COLLEGE  OF  OSTEOPATHY.  A  stock  company,  established  in  1896. 

Entrance  requirement:  Ostensibly  high  school  graduation;  but  "mature  men  and 
women  who  have  been  in  business  are  given  a  chance  and  usually  make  good." 

Attendance:  85. 

Teaching  staff:  38,  19  being  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $12,750  (estimated). 

Laboratory  facilities:  The  school  has  an  ordinary  chemical  laboratory,  a  fairly 
equipped  laboratory  for  pathology,  histology,  and  bacteriology,  with  a  private 
laboratory  for  the  instructor  in  these  branches  adjoining,  the  usual  dissecting- 
room,  and  a  limited  amount  of  apparatus  for  experimental  work  in  physiology. 

Clinical  facilities :  A  dispensary  is  carried  on  at  the  school,  which  also  owns  a  hospital 
for  obstetrical  and  surgical  cases.  The  catalogue  fails,  however,  to  state  that  the 
students  have  no  regular  work  in  this  hospital.  They  rarely  see  medical  cases; 
"they  don't  have  as  much  acute  work  as  they  should."  Nevertheless,  they  are 
drilled  to  "treat  gonorrhea  by  diet  and  antiseptics;  syphilis  with  ointments  and 
dietetics,  and  without  mercury;  typhoid,  pneumonia,  etc.,"  along  the  same  lines. 

Date  of  visit :  May,  1909. 

OAKLAND:  Population,  73,812. 

(6)  COLLEGE  OF  MEDICINE  AND  SURGERY.  Established  1902  as  a  stock  company,  stock 
partly  subscribed  by  merchants  of  the  town. 

1 "  People  are  ready  to  pay  for  relief  from  distress  and  sickness.  It  is  only  fair  to  say  that  many  of 
our  graduates  are  earning  as  much  in  single  months  as  they  were  formerly  able  to  earn  by  a  full 
years  work."  (Catalogue,  p.  9.) 


192  MEDICAL  EDUCATION 

Entrance  requirement:  "High  school  or  equivalent.** 

Attendance:  17. 

Teaching  staff:  82,  13  being  professors.  There  are  no  full-time  teachers. 

Resources  available  for  maintenance:  The  school  lives  on  fees,  amounting  to  $2760 
(estimated),  and  on  contributions  from  the  faculty. 

Laboratory  facilities:  It  occupies  a  new,  well  kept  building,  has  a  small  laboratory 
for  experimental  physiology,  small  separate  laboratories  for  bacteriology,  histo- 
logy, and  pathology,  a  beautiful,  though  not  extensive,  collection  of  pathological 
specimens,  a  laboratory  for  chemistry,  a  dissecting-room  with  provision  for  model- 
ing, and  a  small  library  of  slight  value.  Though  there  are  no  full-time  teachers, 
there  is  evidence  of  active  interest  in  pathology.  Post-mortems  are  abundant  and  are 
intelligently  used,  through  a  fortunate  connection  of  the  instructor  in  pathology. 

Clinical  facilities :  In  respect  to  both  dispensary  and  hospital,  the  clinical  facilities 

are  decidedly  inadequate. 
Date  ofvitit:  May,  1909. 

SAN  FRANCISCO:  Population,  355,919. 

(7)  UNIVERSITY  OF  CALIFORNIA  MEDICAL  DEPARTMENT.  Established  as  such  1872.  An 
organic  department  of  the  university.  The  first  and  second  years'  work  is  given 
at  Berkeley.  See  (2). 

Entrance  requirement:  Two  years  of  college  work,  strictly  enforced. 
Attendance:  36,  all  but  2  from  California, 

Teaching  staff:  60,  of  whom  12  are  professors.  The  laboratory  courses  at  Berkeley 
are  given  by  full-time  teachers. 

Resources  available  for  maintenance:  The  department  shares  the  university  funds,  its 
budget  calling  for  $33,396.  The  total  receipts  from  fees  are  $7004. 

Laboratory  facilities:  The  equipment  and  instruction  are  of  the  highest  quality.  The 
laboratories,  though  temporary  in  structure,  are  completely  fitted  up,  in  charge 
of  high-grade  teachers,  abundantly  provided  with  assistants  and  helpers.  The  sole 
question  to  be  raised  concerns  the  medical  atmosphere,  which,  in  several  depart- 
ments, is  not  strongly  in  evidence.  In  consequence,  post-mortem  work  has  not 
been  hitherto  cultivated,  though  abundant  opportunities  for  it  exist.  The  bio- 
logical point  of  view  prevails.  This  is  not  the  case  with  anatomy,  the  teaching 
of  which — thoroughly  scientific  in  method  and  spirit — frankly  meets  the  main 
purpose  of  the  students. 

Clinical  facilities :  Clinical  instruction  is  given  in  San  Francisco.  The  university  hos- 
pital, its  main  reliance,  is  small  but  modern.  It  contains  75  beds,  practically  all 


CALIFORNIA  198 

available  for  instruction.1  Bedside  teaching  is  carried  on;  but  post-mortem  work 
for  the  benefit  of  the  students  is  meager.  Some  additional  clinical  work  is  procured 
at  hospitals  maintained  by  the  city  and  by  the  United  States  government.  In 
general,  the  laboratory  and  clinical  departments  are  not  as  yet  effectively  correlated. 
The  teachers  of  the  third  and  fourth  years  are,  excepting  the  dean,  practitioners 
who  are  not  in  touch  with  the  laboratory  work  and  ideals  as  realized  at  Berkeley. 
Efforts  are,  however,  making  to  bridge  the  gap. 

The  hospital  is  unfortunately  situated  from  the  standpoint  of  a  dispensary;  such 
material  as  there  is,  is  not  well  used  from  a  teaching  point  of  view.  The  students 
do  not  in  all  departments  take  an  active  part  in  the  dispensary  work.  For  example, 
in  some  of  them  they  have  nothing  to  do  with  making  up  the  records,  which  are 
separately  kept  in  the  several  departments.  No  report,  showing  the  number  of  the 
distribution  of  cases,  is  obtainable. 
Date  of  visit:  May,  1909. 

(8)  LELAND  STANFORD  JUNIOR  UNIVERSITY  SCHOOL  OF  MEDICINE,  ON  THE  COOPER  MEDI- 
CAL COLLEGE  FOUNDATION.  Until  1908,  the  Cooper  Medical  College  offered  a  four- 
year  course  based  on  high  school  graduation.  Its  property  has  now  been  deeded 
to  Stanford  University,  its  buildings  being  the  seat  of  the  clinical  department  of 
Stanford  University  School  of  Medicine,  the  instruction  of  the  last  five  semesters 
being  given  in  Cooper  Hall  and  Lane  Hospital.  That  of  the  first  three  semesters 
is  given  at  Palo  Alto.  As  its  present  classes  graduate,  the  Cooper  Medical  College 
passes  out  of  existence  and  its  faculty  disbands. 

Entrance  requirement :  Three  years  of  college  work. 

Attendance:  16  in  first  year  (fourth  collegiate  year).  No  other  year's  work  has  yet 
been  given. 

Teaching  staff:  21,  of  whom  16  are  professors.  Six  professors  and  one  assistant  pro- 
fessor give  their  entire  time  to  medical  work.  The  clinical  professors  thus  far 
chosen  have  been  taken  from  the  former  faculty  of  the  Cooper  Medical  College. 

Resources  available  for  maintenance :  The  department  will  share  in  the  general  in- 
come of  the  university.  A  special  library  endowment  amounts  to  about  $250,000. 

Laboratory  facilities :  These  are  provided  at  Palo  Alto  on  the  same  scale  as  other 
departments  there  (anatomy,  pharmacology,  bacteriology,  physiology,  physio- 
logical chemistry).  The  school  has  an  unusually  valuable  library  of  some  85,000 
volumes  and  receives  the  main  current  medical  periodicals,  American  and  foreign. 

Clinical  facilities:  Clinical  work  on  the  part  of  Stanford  University  is  not  yet  begun. 
The  university  now  owns  the  Lane  Hospital  of  125  beds,  which  has  hitherto  been 
conducted  as  a  pay  institution.  Patients  paying  $10  a  week  are  used  for  clinical 

1  During  four  months  of  1909,  there  was  a  daily  average  of  44  free  patients. 


194  MEDICAL  EDUCATION 

teaching ;  seventy -odd  beds  are  thus  available,  part  of  these  being  temporarily 
supported  by  the  city.1  The  hospital  is  now  under  temporary  control  of  Cooper 
Medical  College  until  needed  by  the  university.  Its  organization  at  present,  from 
the  teaching  point  of  view,  is  seriously  defective.  Records  are  meager ;  no  surgical 
rounds  are  made  in  the  wards ;  obstetrical  work  exists  only  in  the  form  of  an  out- 
patient department;  post-mortems  are  scarce.  No  hospital  report  is  obtainable. 
The  catalogue  statement  that  the  hospital  is  a  teaching  hospital  is  hardly  sus- 
tained by  the  facts. 

The  dispensary  in  the  college  building  adjoining  had  in  1907  an  attendance  of 
20,000,  including  both  old  and  new  cases.  But  the  material,  though  adequate  in 
amount,  was  not  thoroughly  used  by  the  Cooper  Medical  College. 
Date  ofvirit:  May,  1909. 

(9)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Established  1896.  An  independent  school. 
Entrance  requirement:  "High  school  education  or  equivalent." 

Attendance:  70. 

Teaching  staff":  53,  23  being  professors.  There  are  no  full-time  teachers. 

Resources  available  for  maintenance:  The  institution  has  no  resources  but  fees, 
amounting  to  $7715  (estimated). 

Laboratory  facilities :  The  school  has  no  laboratories  worthy  the  name. 
Clinical  facilities:  There  are  no  adequate  clinical  or  dispensary  facilities. 
Date  ofvitit:  May,  1909. 

(10)  HAHNEMANN  MEDICAL  COLLEGE  OF  THE  PACIFIC.  Established  1881.  Homeopathic. 
An  independent  school. 

Entrance  requirement:  "High  school  graduation  or  equivalent." 

Attendance:  23. 

Teaching  staff":  35,  13  being  professors,  none  of  them  full-time  teachers. 

Resources  available  for  maintenance:  The  institution  has  practically  no  resources 
but  fees,  amounting  to  $2685  (estimated). 

Laboratory  facilities:  The  school  occupies  a  small,  well  kept  building  containing  the 
usual  dissecting-room,  a  laboratory  for  elementary  chemistry,  one  fairly  equipped 
laboratory  in  common  for  histology,  bacteriology,  and  pathology,  and  a  small 
orderly  library. 

Clinical  facilities :  Several  neatly  kept  but  inadequately  equipped  rooms  are  set  aside 
for  a  dispensary ;  the  attendance  is  fair,  the  records  meager.  The  main  clinical  reli- 

1  During  four  months  of  1909,  there  was  a  daily  average  of  60. 


CALIFORNIA  195 

ance  now  is  on  a  small  number  of  beds  paid  for  by  the  city  in  the  Hahnemann 
Hospital,  a  modern  institution  close  by.1 
Date  of  visit:  May,  1909. 

General  Cormderations 

CONSIDERATION  of  medical  education  in  California  may  well  start  from  the  fact  that, 
without  taking  into  account  the  osteopaths — who  abound — the  state  has  now  one 
physician  to  every  401  inhabitants,  that  is,  in  round  numbers,  about  four  times  as 
many  doctors  as  it  needs  or  can  properly  support.  Such  an  enormous  disproportion 
can  hardly  be  rectified  within  less  than  a  generation ;  it  makes  radical  measures  in  the 
interest  of  sound  medical  education  not  only  immediately  feasible,  but  urgently 
necessary. 

Legal  enactment  fixing  a  sound  basis  for  future  practitioners,  of  whatever  school, 
the  grant  of  authority  to  the  state  board  to  close  schools  flagrantly  defective  in 
either  laboratory  or  clinical  facilities,  or  the  institution  of  practical  examinations 
for  license, — any  one  of  these  measures  would  at  once  wipe  out  at  least  seven  of  the 
ten  existing  schools,  with  distinct  advantage  to  the  public  health  of  the  state.  As 
none  of  these  schools  has  the  resources  indispensable  to  meet  the  rising  tide  in 
medical  education,  this  outcome  is  in  any  case  inevitable;  legal  regulation  of  the 
type  indicated  would  merely  hasten  the  day. 

Even  then  the  situation  of  medical  education  in  the  state  is  not  altogether  clear. 
The  University  of  California  has  not  yet  solved  its  problem.  The  sums  it  now  devotes 
to  medical  education  are  relatively  small;  its  clinical  facilities  in  San  Francisco  are 
inadequate;  it  has  not  effectively  organized  what  it  there  offers;  it  has  not  brought 
about  team  work  between  the  two  severed  branches  that  constitute  the  department. 
If  now  it  has  proved  difficult  to  perfect  an  organization  covering  two  places  separated 
by  San  Francisco  Bay,  what  reason  is  there  to  be  confident  when  the  distance  involved 
is  five  hundred  miles  ?  Nor  does  any  practical  need  compel  a  step  educationally  ques- 
tionable. The  attendance  in  Los  Angeles  in  the  last  two  years  on  a  high  school  or 
equivalent  basis  is  less  than  thirty ;  it  will  fall  still  lower  when  the  two-year  college 
basis  is  enforced  and  transplantation  from  Berkeley  to  Los  Angeles  is  required  at 
the  beginning  of  the  third  year.  Moreover,  the  clinical  prospects  are  by  no  means 
up  to  university  standard.  The  dispensary  may  indeed  be  adequately  developed,  but 
one  hundred  beds  in  the  general  medical  and  surgical  wards  of  an  old-fashioned 
public  hospital,  however  supplemented  by  courtesies  elsewhere,  constitute  a  fragile 
support  for  a  university  department  of  medicine.  The  difficulty  of  controlling  the 
teaching  at  Los  Angeles  by  the  scientific  ideals  of  the  university  at  Berkeley  can 
hardly  be  overstated.  Finally,  with  the  present  needs  of  the  clinical  department  at 
San  Francisco,  it  is  not  likely  that  the  university  can  divert  to  Los  Angeles  the  sums 
necessary  to  create  a  satisfactory  department  there.  The  move  is  explained  on  the 

1  During  four  months  of  1909  there  was  a  daily  average  of  55  city  patients. 


196  MEDICAL  EDUCATION 

ground  that  peculiar  conditions  exist  in  the  state;  it  is,  however,  not  clear  why  a 
long  narrow  state  is  educationally  in  any  different  plight  from  a  short  broad  one; 
in  either  case,  needless  multiplication  of  medical  schools  is  economically  wasteful  and 
professionally  demoralizing. 

The  university  has  undertaken  to  dominate  two  detached  clinical  departments, 
manned  by  local  practitioners.  There  is  nothing  in  the  present  status  of  detached 
clinical  departments  of  this  type  to  encourage  confidence  in  the  outcome.  Before  too 
far  committing  itself  to  this  policy,  it  is  at  least  worth  inquiring  into  the  advis- 
ability of  concentrating  its  medical  instruction  across  the  bay,  where  a  population  of 
over  two  hundred  thousand  affords  sufficient  clinical  material,  and  where  a  compact, 
effective,  and  organically  whole  university  department  of  medicine,  with  a  faculty, 
laboratory  and  clinical,  selected  on  educational  principles,  could  be  readily  developed. 

These  considerations  apply  in  some  respects  with  equal  force  to  the  action  of 
Stanford  University  in  taking  over  the  Cooper  Medical  College  at  San  Francisco. 
It  was  well  enough  to  offer  the  laboratory  sciences  at  Palo  Alto,  where  the  resources 
and  ideals  of  the  university  insure  high-grade  instruction ;  but  the  entrance  of  the 
university  into  the  San  Francisco  field  in  all  probability  portends  the  division  and  re- 
striction of  whatever  opportunities  the  city  may  hereafter  create.  Lane  Hospital  can 
be  developed  into  a  teaching  hospital  of  adequate  size  only  if  very  large  sums  are 
available  for  the  purpose;  its  organization  and  conduct  have  been  in  the  past  peda- 
gogically  very  defective;  and  the  clinical  professors  so  far  appointed  have  been  taken 
with  one  exception  from  the  former  Cooper  faculty.  With  one  university  medical 
school  already  on  the  ground,  a  second — and  a  divided  school  at  that  —  is  therefore 
a  decidedly  questionable  undertaking.  There  is  no  need  of  it  from  the  standpoint 
of  the  public ;  it  must,  if  adequately  developed,  become  a  serious  burden  upon  the 
finances  of  Stanford  University.  If  the  experience  of  other  schools  and  cities  is  to  be 
heeded,  the  question  arises  whether  Stanford  would  not  do  well  to  content  itself  with 
the  work  of  the  first  two  years  at  Palo  Alto,  and  to  cooperate  with  the  state  uni- 
versity in  all  that  pertains  to  the  clinical  end. 

The  situation  just  presented  deserves  to  be  studied  carefully  by  all  interested  in 
medical  education.  What  has  happened  in  California  is  likely  to  happen  elsewhere. 
Scores  of  schools  are  beginning  a  desperate  struggle  for  existence.  Their  first  impulse 
is  to  throw  themselves  into  the  lap  of  some  prosperous  university.  The  universities, 
not  as  yet  themselves  realizing  that  medical  education  is  no  longer  either  profitable 
or  self-supporting,  are  prone  to  complete  themselves  by  accepting  a  medical  depart- 
ment as  an  apparent  gift.  From  the  standpoint  of  the  university  this  blunder  will 
soon  prove  a  serious  drain,  as  increased  expenditure  on  instruction  and  reduced  in- 
come from  fees  reveal  the  actual  state  of  affairs.  From  the  standpoint  of  medical  edu- 
cation and  practice,  the  tendency  in  question  is  still  more  deplorable.  The  curse  of 
medical  education  is  the  excessive  number  of  schools.  The  situation  can  improve 
only  as  weaker  and  superfluous  schools  are  extinguished. 


COLORADO  197 

COLORADO 

Population,  653,506.  Number  of  physicians,  1690.  Ratio,  1:  328. 
Number  of  medical  schools,  2. 

DENVER:  Population,  158,329. 

(1)  DENVER  AND  GROSS  COLLEGE  OF  MEDICINE.  Organized  by  consolidation  1902.  No- 
minally the  medical  department  of  the  University  of  Denver,  with  which  institu- 
tion it  has,  however,  only  a  six  months'  contract;  to  all  intents  and  purposes,  a 
proprietary  school,  managed  by  its  own  faculty. 

Entrance  requirement;  Less  than  high  school  graduation,  loosely  enforced. 
Attendance:  109,  over  one-half  from  Colorado. 

Teaching  staff:  44  professors  and  35  of  other  grade,  none  of  them  giving  their 
whole  time  to  teaching. 

Resources  available  for  maintenance:  The  school  has  no  resources  but  fees,  amounting 
to  $12,624  per  annum  (estimated). 

Laboratory  facilities :  Its  equipment  consists  of  a  chemical  laboratory  of  the  ordinary 
medical  school  type,  a  dissecting-room,  containing  a  few  subjects  as  dry  as  leather, 
a  physiological  laboratory  with  slight  equipment,  and  the  usual  pathology  and 
bacteriology  laboratories.  There  is  atotal  absence  of  scientific  activity.  The  rooms  are 
poorly  kept.  A  few  cases  of  books  are  found  in  the  college  office  behind  the  counter. 

Clinical  facilities:  The  college  owns  a  new  and  exceedingly  attractive  dispensary 
building.  Separate  rooms  nicely  equipped  are  occupied  by  the  various  specialties. 
The  attendance  averages  90  a  day;  the  records  are  inadequate.  There  is  an  out- 
patient obstetrical  service. 

For  hospital  facilities  the  school  depends  largely  on  the  County  Hospital,  the 
management  of  which  is  political.  Clinics  are  held  daily  from  8.30  to  10,  "purely 
through  courtesy."  Students  from  all  schools  merely  "look  on ;"  they  are  "not  much 
at  the  bedside."  Obstetrical  work  is  limited,  post-mortems  rare.  Hospital  staff  ap- 
pointments are  secured  through  "pull;"  the  college  must  take  into  the  faculty 
the  men  who  are  already  on  the  hospital  staff.  Supplementary  opportunities  are  fur- 
nished by  several  local  institutions.  In  several  of  these,  however,  the  clinics  are  not  re- 
gularly scheduled:  "announcements  appear  upon  the  bulletin  board  of  the  college." 

Date  of  visit:  April,  1909. 

BOULDER:  Population,  9,652. 

(2)  UNIVERSITY  OF  COLORADO  SCHOOL  OF  MEDICINE.  Organized  1883.  An  integral  part 
of  the  university. 


198  MEDICAL  EDUCATION 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent.  Creden- 
tials are  passed  on  by  the  dean. 

Attendance:  85. 

Teaching  staff":  45,  of  whom  25  are  professors,  20  of  other  grade. 

Resources  available  for  maintenance:  The  school  is  supported  out  of  the  total  uni- 
versity income  of  $200,000  per  annum.  Its  fee  income  is  $4043;  its  budget,  $28,000. 

Laboratory  facilities:  The  school  is  in  general  satisfactorily  equipped  to  do  under- 
graduate teaching  in  the  medical  sciences.  Full-time  men  are  in  charge  of  patho- 
logy, bacteriology,  and  physiology,  though  the  departments  lack  trained  assistants. 
Histology  and  embryology  are  taught  in  the  department  of  biology.  The  chair  of 
anatomy  is  occupied  by  a  non-resident  surgeon.  There  is  a  good  library,  with  a 
subscription  list  including  the  best  German  and  English  journals.  A  regular  fund 
is  available  for  the  purchase  of  books  and  apparatus. 

Clinical  facilities :  The  university  hospital  is  entirely  inadequate,  even  though  the 
school  is  small.  It  contains  35  beds  and  averages  16  patients  available  for  teaching. 
Its  management  has  only  recently  been  modernized.  It  now  contains  a  clinical 
laboratory  where  students  work,  keeping  excellent  records  of  their  findings.  There 
are  from  12  to  15  obstetrical  cases  annually  in  the  hospital;  these  are  supple- 
mented by  an  out-patient  service. 
The  dispensary  is  slight. 

Date  ofvirit:  April,  1909. 

General  Considerations 

THE  state  is  overcrowded  with  doctors.  It  can  therefore  safely  go  to  a  higher  stand- 
ard; indeed,  the  new  law  provides  that  after  1912,  all  applicants  for  license  must 
have  had,  previous  to  their  medical  education,  a  year  of  college  work.  As  this  is  a 
practice,  and  not  an  educational,  requirement,  the  Denver  school  may  still  continue 
to  train  low-grade  men  for  adjacent  states;1  but  it  is  probable  that  if  it  continues 
on  a  standard  below  the  legal  practice  minimum,  it  will  be  too  discredited,  and  if  it 
arises  to  the  aforesaid  minimum,  too  much  reduced,  to  continue.  The  state  univer- 
sity alone,  so  far  as  we  can  now  see,  can  hope  to  obtain  the  financial  backing  neces- 
sary to  teach  medicine  in  the  proper  way  regardless  of  income  from  fees,  and  to  it 
a  monopoly  should  quickly  fall.  Its  laboratory  facilities  are  steadily  increasing,  but 
adequate  clinical  resources  are  not  at  present  assured.  It  is  important,  therefore,  that 
as  a  first  step  the  state  university  gain  access  to  the  clinical  facilities  at  Denver, 
from  which  it  is  now  cut  off,  first,  by  a  constitutional  provision  forbidding  the  state 
university  to  teach  except  at  Boulder,  second,  by  the  fact  that  the  City  Hospital  is 

1  It  is.  however,  equally  in  the  interest  of  these  states  that  a  further  low-grade  supply  should  be  cut 
off.  Though  none  of  the  following  states  has  a  medical  school,  all  have  too  many  doctors.  The  ratios 
are:  Wyoming,  1 :  541 ;  Arizona,  1 :  627 ;  Idaho,  1 :  663;  New  Mexico,  1 :  618. 


CONNECTICUT  199 

in  the  hands  of  the  local  school.  These  conditions,  so  common  in  American  cities,  are 
plainly  against  the  general  interest  of  the  community.  It  may  be  that  an  arrangement 
can  be  made  by  which  the  Denver  and  Gross  school  will  be  handed  over  to  the  uni- 
versity, thus  clearing  the  field  of  all  obstacles  to  the  upbuilding  of  a  creditable  school ; 
for  as  Boulder  is  practically  a  suburb  of  Denver,  the  difficulties  in  the  way  of  effective 
management  at  Denver  are  not  insuperable.  Whether  the  entire  medical  school  shall 
be  permanently  concentrated  at  Denver  or,  following  the  Ann  Arbor  plan,  a  liberally 
supported  hospital  at  Boulder  be  relied  on  to  overcome  the  disadvantage  of  location 
in  the  matter  of  clinical  material,  need  not  be  decided  just  now.  The  important  steps 
to  take  at  this  moment  comprise  (1)  passage  of  the  constitutional  amendment  open- 
ing the  clinical  facilities  of  Denver  to  the  state  university,  (2)  more  liberal  state  ap- 
propriations for  the  medical  school,  and  (3)  the  consolidation  of  the  Denver  and 
Boulder  schools  as  the  medical  department  of  the  state  university.1 


CONNECTICUT 

Population,  1,054,366.  Number  of  physicians,  1424.  Ratio,  1 : 740. 
Number  of  medical  schools,  1. 

NEW  HAVEN  -.Population,  130,027. 

YALE  MEDICAL  SCHOOL.  Organized  1813.  An  organic  part  of  Yale  University. 

Entrance  requirement:  Two  years  of  college  work,  enforced  with  such  unusual  con- 
scientiousness that  in  passing  from  the  high  school  to  the  college  standard  this 
year,  deficient  members  of  last  year's  class  were  refused  re-admission.  Moreover, 
the  advanced  requirement  has  been  actually  exacted;  out  of  an  entering  class  of 
23,  one  only  is  conditioned, — in  part  of  biology.  This  is  probably  the  lowest  per- 
centage of  "conditions"  that  the  country  affords. 

Attendance:  138;  72  per  cent  from  Connecticut. 

Teaching-  staff':  64,  14  being  professors.  Of  these,  the  teachers  in  the  fundamental 
branches  devote  full  time  to  instruction,  though  they  are  overworked  and  without 
a  proper  force  of  assistants;  in  the  clinical  branches,  the  professor  of  medicine 
with  two  assistants  is  salaried.  Small  sums  are  also  paid  to  a  few  other  teachers  in 
the  clinical  years. 

Resources  available  for  maintenance:  Fees  amounting  to  $15,325,  income  from  en- 
dowment amounting  to  $10,000,  university  appropriation  of  $17,986,  making 
annual  budget  $43,311. 

Laboratory  facilities:  Well  equipped  student  laboratories  for  organic  chemistry, 

1  As  this  Report  goes  to  press,  announcement  is  made  that  a  consolidation  of  the  Denver  and  Gross 
School  with  the  medical  department  of  the  state  university  has  been  arranged. 


200  MEDICAL  EDUCATION 

physiology,  and  pharmacology;  the  provision  for  bacteriology,  pathology,  and 
anatomy  is  less  satisfactory.  In  physiology  alone  is  there  internal  evidence  of  pro- 
gressive activity.  The  instructors  in  other  branches  are  overworked,  being  called 
on  to  carry  the  routine  work  of  extensive  subjects  in  all  their  parts  without  ade- 
quate assistance.  Under  such  circumstances,  the  work,  however  conscientious,  is 
bound  to  be  limited. 

Clinical  facilities :  The  New  Haven  Hospital,  in  which  the  school  controls  a  small 
number  of  beds,  is  very  intelligently  employed.  The  obstetrical  and  gynecological 
wards,  however,  are  not  used  for  teaching;  nor  is  there  a  contagious  disease  pa- 
vilion. Post-mortems  are  scarce.  Clinical  laboratories  and  teaching-rooms  have 
been  improvised  close  by  the  hospital;  students  are  thereby  enabled  to  do  the 
clinical  laboratory  work  in  connection  with  assigned  cases.  Provision  is  also  made 
there  for  the  independent  work  of  the  professors  of  medicine  and  surgery. 

The  dispensary  occupies  a  new  and  excellent  building,  but  lacks  systematic 
organization  as  a  teaching  adjunct.  The  attendance  is  adequate;  but  as  the  staff 
service  is  gratis,  it  varies  greatly  in  quality  in  various  departments. 

Date  of  visit :  January,  1910. 

General  Considerations 

As  the  school  now  stands,  it  would,  in  point  of  facilities,  still  have  to  be  classed  with 
the  better  type  of  those  on  the  high  school  basis;  for,  though  it  has  advanced  to  a 
two-year  college  basis,  there  has  been  as  yet  no  corresponding  improvement  of  facili- 
ties. In  order  to  deserve  the  higher  grade  student  body  which  it  invites,  a  more  liberal 
policy  ought  to  be  pursued.  The  laboratory  branches  ought  to  be  better  manned,  so 
that  the  instructors  may  create  within  them  a  more  active  spirit.  A  university  depart- 
ment of  medicine  cannot  largely  confine  itself  to  routine  instruction, — certainly 
not  after  requiring  two  years  of  college  work  for  admission  to  its  opportunities. 
For  the  same  reason  the  clinical  facilities  should  be  extended,  probably  through  a 
more  intimate  connection  with  the  present  hospital.  Its  wards  should  be  more  gener- 
ally used;  more  beds  should  be  made  accessible  within  them;  and  the  missing  pavilion 
for  contagious  diseases  be  provided.  Enough  money  ought  to  be  spent  on  the  dispen- 
sary to  ensure  in  every  department  systematic  and  thorough  discipline,  in  examining 
patients,  keeping  records,  etc. 

To  make  these  improvements,  larger  permanent  endowment  is  required.  As  the 
school  is  one  of  a  very  few  in  New  England  so  circumstanced  as  to  have  a  clear  duty 
and  opportunity,  it  behooves  the  university  to  make  a  vigorous  campaign  in  behalf 
of  its  medical  department. 

[For  gtneral  ditcutrion  t«4  "  New  England"  p.  261.] 


DISTRICT  OF  COLUMBIA  201 

DISTRICT  OF  COLUMBIA 

Population,  322,212.  Number  of  physicians,  1231.  Ratio,  1 :  262. 
Number  of  medical  schools  3,  plus  two  postgraduate  (Army  and  Navy  Medical) 
schools. 

WASHINGTON:  Population,  327,044. 

(1)  GEORGE  WASHINGTON  UNIVERSITY,  DEPARTMENT.  OF  MEDICINE.  Organized  1825. 
Now  an  integral  department  of  the  university. 

Entrance  requirement:  Less  than  a  four-year  high  school  course. 
Attendance:  117. 

Teaching  staff:  69  instructors,  25  being  professors,  none  of  whom  is  a  full-time  teacher; 
three  instructors  of  other  grade  devote  entire  time  to  the  school. 

Resources  available  for  maintenance:  The  school  budget  calls  for  $23,779;  its  income 
in  fees  is  $21,833;  the  hospital  is  self-supporting. 

Laboratory  facilities:  The  laboratories  of  physiology,  pathology,  chemistry,  and 
anatomy  are  well  equipped ;  the  building  is  admirably  kept,  and  there  is  evidence 
of  independent  activity  on  the  part  of  the  several  instructors.  Animals  are  pro- 
vided; there  is  a  fair  library  enjoying  a  small  annual  appropriation,  and  a  small 
but  attractive  museum.  Post-mortems  are  scarce. 

Clinical  facilities:  The  University  Hospital  and  Dispensary,  under  complete  control, 
adjoins  the  medical  school;  56  beds  are  available  for  teaching  purposes.  The  staff 
has  been  recently  reorganized  on  modern  lines  in  order  to  increase  the  scope  of 
bedside  work.  Supplementary  opportunities  are  furnished  under  the  usual  condi- 
tions by  several  other  hospitals. 

The  dispensary  has  an  annual  attendance  of  something  over  1000. 

Date  of  visit:  March,  1909. 

(2)  GEORGETOWN  UNIVERSITY  SCHOOL  OF  MEDICINE.  Organized  1851.  A  university 
department  in  name  only. 

Entrance  requirement:  Less  than  a  four-year  high  school  course. 
Attendance:  89. 

Teaching  staff :  74,  of  whom  20  are  professors;  no  one  gives  whole  time  to  the  medi- 
cal school,  except  the  dean,  who  has  the  chair  of  hygiene  and  is  treasurer  of  both 
medical  and  dental  schools. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $11,000  a  year. 
Laboratory  facilities :  The  equipment  consists  of  a  good  dissecting-room,  a  single 


202  MEDICAL  EDUCATION 

fairly  well  stocked  laboratory  for  pathology,  bacteriology,  and  histology,  a  fair 
equipment  for  experimental  physiology,  and  an  ordinary  chemical  laboratory. 
There  is  no  library  accessible  to  students,  no  museum,  and  no  pharmacological 
laboratory. 

Clinical  facilities:  The  school  has  recently  built  a  hospital,  in  which  there  are  100 
ward  beds,  not  free,  but  available  for  clinical  use.  It  is  several  miles  distant.  The 
usual  supplementary  clinics  are  held  in  other  places  also.  A  few  rooms  at  the  hos- 
pital are  set  aside  for  a  dispensary;  the  attendance  is  small. 

Datt  ofvirit:  March,  1909. 

(3)  HOWARD  UNIVERSITY  MEDICAL  COLLEGE.  Organized  1869.  An  integral  part  of 
Howard  University. 

Entrance  requirement:  A  high  school  course  or  its  equivalent. 

Attendance:  205,  most  of  whom  are  working  their  way  through.  Practically  all  the 
students  are  colored. 

Teaching  staff:  52,  22  being  professors,  30  of  other  grade. 

Resources  available  for  maintenance:  The  school  budget  calls  for  $40,000,  of  which 
§26,000  are  supplied  by  student  fees,  most  of  the  remainder  by  government  appro- 
priation. Though  the  school  has  been  changed  from  a  night  to  a  day  school,  the 
fees  raised  from  $80  to  $100,  and  the  admission  requirements  stiffened,  the  at- 
tendance has  nevertheless  increased. 

Laboratory  facilities :  The  laboratory  equipment  includes  anatomy,  pathology,  his- 
tology, bacteriology,  and  chemistry.  There  is  no  organized  museum,  though  the 
school  possesses  a  number  of  specimens,  normal  and  pathological,  charts,  models,  etc. 

Clinical  facilities :  Clinical  facilities  are  provided  in  the  new,  thoroughly  modern,  and 
adequate  government  hospital  of  278  free  beds,  with  its  dispensary,  closely  identi- 
fied with  the  medical  school.  A  pavilion  for  contagious  diseases  alone  is  lacking. 

Datt  of  visit:  January,  1910. 

(4)  ARMY  MEDICAL  SCHOOL.  Organized  1822.  Offers  laboratory  courses,  covering 
eight  months,  to  candidates  who  have  passed  their  preliminary  examinations  as 
army  surgeons. 

Attendance:  57. 

Teaching  staff:  10  instructors,  detached  from  the  army  for  the  purpose. 

Laboratory  facilities :  Excellent  teaching  and  working  laboratories  in  cramped  quar- 
ters are  provided  in  the  building  occupied  by  the  great  library  and  museum  of  the 
Surgeon -General's  office. 

DaU  of  vitit :  January,  1910. 


GEORGIA  203 

(5)  NAVY  MEDICAL  SCHOOL.  Offers  laboratory  courses,  covering  six  months,  to  candi- 
dates who  have  passed  preliminary  examinations  as  navy  surgeons. 

Attendance:  20. 

Teaching  staff":  Several  instructors,  detached  from  the  service  for  three  years  or  less. 

Laboratory  facilities:  Good  teaching  and  working  laboratories  are  provided  in  the 

building  formerly  used  for  the  naval  observatory. 
Date  of  visit :  January,  1910. 

General  Considerations 

OF  the  medical  schools  in  Washington,  Howard  University  has  a  distinct  mission 
— that  of  training  the  negro  physician — and  an  assured  future.  The  government 
has  to  some  extent  been  the  patron  of  the  institution,  and  has  done  its  medical  de- 
partment an  incalculably  great  service  by  the  erection  of  the  Freedman's  Hospital. 
Sound  policy — educational  as  well  as  philanthropic — recommends  that  this  hospital 
be  made  a  more  intimate  part  of  Howard  University,  so  that  students  may  profit 
to  the  uttermost  by  its  clinical  opportunities.  Its  usefulness  as  a  hospital  in  its  im- 
mediate vicinity  will  be  thereby  increased;  and  its  service  to  the  colored  race  at  large 
will  be  augmented  to  the  extent  to  which  it  is  used  to  educate  their  future  physicians. 
The  other  two  schools  lack  adequate  resources  as  well  as  assured  prospects.  They 
are  surrounded  by  medical  schools — those  of  Richmond,  Baltimore,  Philadelphia — 
whose  competition  they  cannot  meet.  Finally,  the  District  of  Columbia  has  relatively 
more  physicians  than  any  other  part  of  the  country.  Should  the  District  require,  as 
it  ought,  a  higher  basis,  or  even  enforce  an  actual  four-year  high  school  standard, 
both  would  suffer  seriously.  Neither  school  is  now  equal  to  the  task  of  training  phy- 
sicians of  modern  type. 

GEORGIA 

Population,  2,557,412.  Number  of  physicians,  2887.  Ratio,  1 :  886. 
Number  of  medical  schools,  5. 

ATLANTA:  Population,  118,243. 

(1)  ATLANTA  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  through  merger,  1898. 
An  independent  school. 

Entrance  requirement:  Nominal. 

Attendance:  286,  about  63  per  cent  from  Georgia. 

Teaching  staff:  51,  of  whom  20  are  professors.  None  of  the  teachers  devotes  full  time 
to  the  school. 


204  MEDICAL  EDUCATION 

Resources  available  for  maintenance:  The  school  has  practically  no  resources  but  fees, 
amounting  to  $28,000. 

Laboratory  facilities :  It  is  perhaps  the  best  equipped  of  all  the  schools  of  its  grade; 
it  has  good  buildings,  containing  a  good  dissecting-room, — dissecting  material, 
however,  somewhat  scarce, — a  fairly  equipped  laboratory  for  physiology  and  physio- 
logical chemistry,  one  of  the  same  character  for  histology  and  pathology,  and 
a  separate  laboratory,  well  equipped,  for  bacteriology.  Unfortunately,  the  school 
has  no  full-time  instructors  in  these  branches,  so  that,  what  with  practitioner 
teachers  and  an  inferior  student  body,  the  equipment  cannot  be  used  at  its  real 
value.  There  is  a  small  library,  but  no  museum. 

Clinical  facilities:  Hospital  facilities  are  furnished  by  the  Grady  (free  city)  Hospital, 
close  by.  Except  in  obstetrics,  to  which  department  students  are  not  admitted, 
the  clinical  material  is  fairly  abundant;  but  it  cannot  be  effectively  used,1  and  the 
students  are  so  unappreciative  of  their  opportunities  that  attendance  in  the 
wards  is  very  irregular. 

In  the  school  building  a  large  suite  of  rooms  is  set  aside  for  a  dispensary.  The 
attendance  is  ample,  the  methods  old-fashioned. 

Date  of  visit :  January,  1909. 

(2)  ATLANTA  SCHOOL  OF  MEDICINE.  Organized  1905.  An  independent  school. 
Entrance  requirement:  Nominal. 

Attendance:  230;  not  quite  70  per  cent  from  Georgia. 

Teaching  staff:  44,  of  whom  17  are  professors,  no  one  devoting  whole  time  to  the 
school. 

Resources  available  for  maintenance:  Fees  and  gifts,  amounting  together  to  $20,000- 
$25,000  annually. 

Laboratory  facilities :  Its  laboratory  equipment  is  slight,  though  it  possesses  some 
features  uncommon  in  schools  of  its  type, — an  excellent  projectoscope,  an  X-ray 
machine,  and  a  small,  useful  library.  There  is  no  museum. 

Clinical  facilities:  A  suite  of  rooms  in  fair  condition  only  is  provided  for  a  dispensary. 
Likewise,  in  the  basement  of  the  college,  two  wards,  containing  20  beds,  have  been 
arranged ;  so  far  as  they  go,  they  are  fairly  well  used.  For  the  rest  of  its  clinical 
instruction  the  school  depends  mainly  on  the  Grady  Hospital,  so  far  off,  however, 
that  the  students  do  not  conscientiously  attend. 

Datt  of  visit:  January,  1909. 

(3)  GEORGIA  COLLEGE  OF  ECLECTIC  MEDICINE  AND  SURGERY.  Organized  1877.  An  in- 
dependent institution. 

1  The  consent  of  ward  patients  must  be  obtained  before  bedside  instruction  can  be  given. 


GEORGIA  205 

Entrance  requirement:  Nominal. 

Attendance:  66. 

Teaching  staff:  20,  of  whom  14  are  professors  and  6  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $5655  (estimated). 

Laboratory  facilities:  The  school  occupies  a  building  which,  in  respect  to  filthy  con- 
ditions, has  few  equals,  but  no  superiors,  among  medical  schools.  Its  anatomy  room, 
containing  a  single  cadaver,  is  indescribably  foul;  its  chemical  "laboratory"  is 
composed  of  old  tables  and  a  few  bottles,  without  water,  drain,  lockers,  or  reagents; 
the  pathological  and  histological  "laboratory"  contains  a  few  dirty  slides  and 
three  ordinary  microscopes. 

Clinical  facilities :  The  school  is  practically  without  clinical  facilities.  Its  outfit  in 
obstetrics  is  limited  to  a  tattered  manikin. 

Nothing  more  disgraceful  calling  itself  a  medical  school  can  be  found  anywhere. 
Date  of  visit:  February,  1909. 

(4)  HOSPITAL  MEDICAL  COLLEGE.  Eclectic.  Organized  1908.  This  institution  occupies 
the  rear  of  a  private  infirmary.  Started  in  1908  "on  four  weeks'  notice11  by  seceders 
from  the  Georgia  College  of  Eclectic  Medicine  and  Surgery  (see  (3)  above\'\i  gradu- 
ated 17  doctors  at  the  close  of  its  first  year. 

Entrance  requirement :  Nominal. 

Attendance:  43. 

Teaching-  staff:  16,  all  of  whom  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $3950  (estimated). 

Laboratory  facilities :  In  the  matter  of  equipment,  it  is  impossible  to  say  what  be- 
longs to  the  school  and  what  to  the  infirmary.  At  any  rate,  there  is  only  one  lab- 
oratory with  any  equipment  worthy  the  name, — that  of  pathology  and  bacteriology. 

Clinical  facilities:  The  clinical  facilities  comprise  the  infirmary  above  mentioned,  con- 
taining 16  beds.  It  is,  of  course,  a  pay  infirmary. 
Date  of  visit:  February,  1909. 

AUGUSTA:  Population,  45,582. 

(5)  MEDICAL  COLLEGE  OF  GEORGIA.  Organized  in  1828,  it  has  been  since  1873  nomi- 
nally the  medical  department  of  the  state  university ;  but  it  is  entirely  controlled 
by  its  own  separate  board,  and  "no  liability  for  its  debts  or  expenses  shall  be  in- 
curred by  the  university."1  The  institution  is  therefore  in  effect  a  proprietary  school. 

1  Agreement  between  Medical  College  of  Georgia  and  University  of  Georgia,  article  4. 


206  MEDICAL  EDUCATION 

Entrance  requirement:  Nominal. 

Attendance:  99,  mostly  from  Georgia.  Twenty-six  of  these  hold  free  county  scholar- 
ships, in  addition  to  which  number  the  dean  admits  as  many  more  as  he  pleases, 
generally  at  the  request  of  congressmen.  Eighteen  students  were  admitted  free  in 
this  way  last  year.  Hence  44  of  the  99  students  are  free. 

Teaching  staff*:  33,  of  whom  18  are  professors. 

Resources  available  for  maintenance:  The  institution  has  no  resources  but  fees, 
amounting  to  $6835. 

Laboratory  facilities :  The  school  occupies  a  building  which  contains  an  exceedingly 
foul  dissecting-room,  a  meager  equipment  for  elementary  chemistry,  a  fair  equip- 
ment for  histology  and  pathology,  and  practically  nothing  for  bacteriology.  There 
is  a  small  museum  and  a  collection  of  several  thousand  books  of  mainly  anti- 
quarian interest. 

Clinical  facilities:  The  city  hospital  adjoining,  containing  100  beds, — less  than  half 
of  them  occupied  at  the  time  of  the  inspection, — offers  most  of  the  clinical  facili- 
ties; the  Lamar  Hospital  is  also  available,  but  is  more  than  a  mile  off,  though 
described  in  the  official  catalogue  of  the  state  university  as  "located  only  a  short 
distance  from  the  college."  At  the  city  hospital  the  students  get  no  obstetrical 
work  because  "the  cases  mostly  come  at  night  and  you  can't  get  the  students;"  at 
the  Lamar  Hospital  they  get  none  because  "  they  are  too  busy."  There  is  no  evi- 
dence anywhere  of  clinical  laboratory  work.  It  was  learned  that  at  the  city  hospital 
there  had  been  "two  post-mortems  in  six  years." 

There  is  a  dispensary  at  the  city  hospital,  but  no  records  are  kept. 

Datt  of  visit:  February,  1909. 

General  Considerations 

THE  situation  to  be  dealt  with  in  this  state  is  so  simple  that  there  is  no  room  for 
difference  of  opinion  as  to  what  ought  to  be  done.  That  every  state  in  the  south  is 
overcrowded  with  doctors  is  generally  admitted.  Florida  alone  of  surrounding  states 
lacks  a  medical  school,  and  there  is  an  excess  of  doctors  there  (ratio  1 :  865).  The 
two  eclectic  schools,  as  utterly  incapable  of  training  doctors,  should  be  summarily 
suppressed.  The  Augusta  situation  is  hopeless.  There  is  no  possibility  of  developing 
there  a  medical  school  controlled  by  the  university.  The  site  is  unpropitious,  the  dis- 
tance too  great.  The  university  ought  not  much  longer  permit  its  name  to  be  exploited 
by  a  low-grade  institution,  whose  entrance  terms — if  the  phrase  can  be  used — are 
far  below  that  of  its  academic  department.  It  should  snap  the  slender  thread;  the 
medical  school  will  not  long  survive  amputation. 

Two  schools  remain  at  Atlanta,  a  growing  city  in  close  proximity  to  the  univer- 
sity at  Athens.  It  would  be  easy  to  consolidate  these  two  institutions  to  form  the 


ILLINOIS  207 

medical  department  of  the  University  of  Georgia.  The  department  could  immediately 
adopt  the  general  entrance  requirements  of  the  university,  to  be  enforced  by  the 
university  authorities.  The  faculty  should,  of  course,  be  reconstructed  and  governed 
without  restriction  on  university  lines.  The  city's  growth  ensures  a  fair  clinic  and 
probably  material  aid. 

ILLINOIS 

Population,  5,717,229.  Number  of  physicians,  9744.  Ratio  1 :  586. 
Number  of  medical  schools,  14,  plus  4  postgraduate  schools. 

CHICAGO:  Population,  2,282,927. 

(1)  RUSH  MEDICAL  COLLEGE.  A  divided  school.  Since  1900  the  instruction  of  the 
first  and  second  years  has  been  given  wholly  at  the  University  of  Chicago,  of 
which  it  is  an  integral  part;  the  third  and  fourth  years,  given  at  the  Cook  County, 
the  Presbyterian,  and  the  Children's  Memorial  Hospitals  and  in  the  laboratory 
buildings  adjoining  them,  are  merely  affiliated  with  the  university.  Pedagogically, 
the  two  branches  do  not  form  an  organic  whole. 

Entrance  requirement:  Two  years  of  college  work,  strictly  enforced,  though  a  consid- 
erable part  of  the  entering  class  is  conditioned  in  part  of  the  scientific  require- 
ment. 

Attendance:  488. 

Teaching  staff:  89  professors  and  141  of  other  grade:  total  230.  The  laboratory 
work  is  in  charge  of  men  devoting  their  entire  time  to  teaching  and  research. 

Resources  available  for  maintenance:  The  instruction  provided  by  the  university  is 
paid  for  out  of  the  university  funds  and  costs  annually  $45,738;  the  clinical  divi- 
sion, carried  by  student  fees  and  by  contributions,  costs  $36,714:  a  total  cost  of 
$82,452.  The  total  income  in  fees  is  $60,485. 

Laboratory  facilities :  The  laboratory  branches  are  most  liberally  provided  for  on 
the  university  grounds;  the  laboratories  are  complete  in  number  and  equipment, 
each  manned  by  a  full  staff,  all  the  members  of  which  are  engaged  in  investiga- 
tion as  well  as  in  teaching.  There  is  considerable  difference  of  opinion  among 
those  engaged  in  teaching  the  scientific  subjects  as  to  how  far  the  presentation 
should  be  deliberately  medical  in  aim. 

Clinical  facilities:  Clinical  facilities  are  provided  by  the  Presbyterian  Hospital,  the 
staff  of  which  is  the  faculty  of  the  Rush  Medical  School,  by  the  Cook  County 
Hospital,  and  by  other  connections.  The  Presbyterian  Hospital  is  an  important 
adjunct,  though  thus  far  it  is  not  by  any  means  a  genuine  teaching  hospital.  It 
contains  about  150  beds  available  for  instruction.  The  Cook  County  Hospital  will 


208  MEDICAL  EDUCATION 

be  discussed  in  connection  with  the  general  state  situation.  It  is  sufficient  to  say 
here  that  its  abundant  material  is  in  a  high  degree  valuable,  though  serious  limi- 
tations upon  its  use  exist.  Rush  holds  21  staff  appointments. 
Dispensary  facilities  are  entirely  adequate. 

Datt  of  visit:  April,  1909. 

(2)  NORTHWESTERN  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1859,  it  has  borne 
its  present  title  since  1891.  An  integral  part  of  the  university. 

Entrance  requirement:  One  year  of  college  work,  hitherto  loosely  enforced. 
Attendance:  522. 

Teaching  staff:  54  professors  and  89  of  other  grade:  143  in  all,  ten  of  whom  devote 
their  entire  time  to  the  school. 

Resources  available  for  maintenance:  Except  for  two  professorships,  endowed  to  the 
extent  of  $60,700,  the  department  lives  on  and  pays  for  plant  addition  out  of  its  fees 
now  amounting  to  $89,076. 

Laboratory  facilities :  The  school  has  the  necessary  laboratories,  well  equipped  for 
routine  work ;  more  could  be  done  but  that  the  full-time  teachers  lack  the  neces- 
sary assistants. 

Clinical  facilities:  These  are  provided  by  Mercy  Hospital,  Wesley  Hospital,  the  Cook 
County  Hospital,  and  other  institutions.  The  Wesley  Hospital,  the  staff  of  which 
comes  wholly  from  the  faculty  of  this  school,1  contains  80  free  beds.  It  is,  however, 
not  primarily  a  teaching  hospital,  though  it  might  apparently  be  reorganized  as 
such  with  much  advantage  both  to  itself  and  to  the  medical  school.  The  Cook 
County  Hospital  will  be  discussed  below;  Northwestern  holds  12  staff  appoint- 
ments there.  In  general,  material  is  abundant  in  amount  and  variety;  the  defects 
of  the  situation  arise  from  the  lack  of  financial  resources  and  pedagogical  control. 
Dispensary  requirements  are  amply  met. 

Data  ofvititt:  April,  1909;  December,  1909. 

(8)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  in  1882;  since  1896  nominally 
the  medical  department  of  the  University  of  Illinois,  with  which,  however,  only  a 
contractual  relation  exists. 

Entrance  requirement :  A  high  school  education  or  its  equivalent,  the  latter  hitherto 
very  loosely  interpreted,  though  somewhat  stricter  action  has  been  enforced  this 
year.  The  policy  of  the  institution  had  been  to  accept  students  who  satisfied  the 
Illinois  law  as  administered  by  the  present  state  board ;  the  requirement  has,  there- 
fore, been  more  or  less  nominal.  Advanced  standing  has  been  accorded  to  stu- 
dents from  decidedly  inferior  schools,  some  of  them  among  the  worst  institutions 

1  Students  from  the  American  Medical  Missionary  College  attend  certain  clinics. 


ILLINOIS  209 

in  the  country.  These  students  were  examined,  only  those  who  passed  being  ac- 
cepted; but  the  fact  that,  with  the  teaching  they  have  had,  they  can  pass  is  con- 
clusive as  to  the  nature  of  the  examination. 

Attendance:  517,  about  60  per  cent  from  Illinois. 

Teaching  staff:  198,  of  whom  42  are  professors,  156  of  other  grade. 

Resources  available  for  maintenance :  The  institution  is  practically  dependent  on  its 
fees,  amounting  to  $80,155  (estimated),  and  has  a  large  floating  debt. 

Laboratory  facilities :  The  school  has  the  following  laboratories:  physiology,  well 
equipped;  pharmacology  and  chemistry,  mediocre;  anatomy,  pathology,  and  bac- 
teriology, adequate.  There  are  full-time  professors  of  anatomy  and  physiology, 
without  skilled  assistants  or  helpers.  Their  work  is  limited  to  routine.  The  school 
has  a  large  library. 

Clinkal  facilities:  For  these  the  school  relies  on  the  Cook  County  Hospital,  on  the 
staff  of  which  it  holds  11  appointments,  and  on  a  number  of  other  institutions  to 
which  its  students  are  admitted  under  the  usual  limitations.  Prominent  among 
these  is  the  so-called  "University  Hospital,"  which  may  be  cited  as  a  typical  in- 
stance of  the  misleading  character  of  catalogue  representations.  The  title  itself  is 
a  misnomer;  for  the  hospital  is  a  university  hospital  not  in  the  sense  that  large 
teaching  advantages  exist  for  the  benefit  of  the  university,  but  only  in  the  sense 
that  to  the  existing  opportunities,  restricted  as  they  are,  students  from  other  schools 
are  not  admitted  at  all.  The  catalogue  states  that  "it  contains  one  hundred  beds, 
and  its  clinical  advantages  are  used  exclusively  for  the  students  of  this  college." 
Not,  however,  the  "clinical  advantages"  of  the  "one  hundred  beds,"  for  52  of  them 
are  private.  Its  "clinical  advantages"  shrink  on  investigation  to  three  weekly  am- 
phitheater clinics  of  slight  pedagogic  value  and  four  ward  clinics  in  obstetrics, 
— each  of  the  latter  attended  by  some  12  or  14  students  in  a  ward  containing  13 
beds.  Supplementary  connections  give  access  to  large  surgical  clinics. 
The  dispensary  service  is  in  general  adequate. 

Dates  of  visits:  April,  1909;  December,  1909. 

(4)  CHICAGO  COLLEGE  OF  MEDICINE  AND  SURGERY.  Organized  1901,  and  since  1902 
the  medical  department  of  Valparaiso  (Indiana)  University ;  up  to  1905  an  eclectic 
institution. 

Entrance  requirement :  A  high  school  education  or  its  equivalent,  interpreted  to  in- 
clude anything  that  the  state  board  will  accept. 

Attendance  :The  school  had  an  enrolment  of  315  in  1907-8,  and  of  366  in  1908-9, 
the  senior  class  of  the  former  year  numbering  95,  the  freshman  69.  This  dispro- 
portion is  largely  due  to  the  fact  that  advanced  standing  has  been  indiscriminately 
granted  to  students  who  had  previously  attended  low-grade  institutions,  some  of 


210  MEDICAL  EDUCATION 

them  now  defunct.  Credit  has  been  allowed  to  former  students  of  even  the  worst 
of  the  Chicago  night  schools. 

Teaching  staff:  The  school  has  a  faculty  of  71,  of  whom  87  are  professors.  There  are 
no  full-time  teachers,  though  some  of  the  scientific  branches  are  taught  by  full- 
time  teachers  of  Valparaiso  University,  who  come  to  the  Chicago  department  on 
certain  days  weekly. 

Resources  available  for  maintenance :  Fees,  amounting  to  $43,430  (estimated). 

Laboratory  facilities :  The  equipment  throughout  is  ordinary,  the  usual  laboratories 
being  provided.  There  are  few  teaching  accessories. 

Clinical  facilities :  Clinical  facilities  are  inadequate,  being  limited  in  the  main  to  an 
adjoining  hospital  of  75  beds,  of  which  one-fourth  can  be  used  for  teaching,  and 
to  the  Cook  County  Hospital,  on  the  staff  of  which  the  school  has  two  represen- 
tatives. 

The  dispensary  has  a  fair  attendance  and  is  in  some  respects  well  organized. 

DaU  ofviiit:  April,  1909. 

(5)  BENNETT  MEDICAL  COLLEGE.  Organized  1868,  and  up  to  1909  an  eclectic  school. 
A  stock  company,  practically  owned  by  the  dean  of  the  school :  "  there  are  enough 
others  to  legalize  the  thing." 

Entrance  requirement :  Nominal  compliance  with  the  Illinois  law  on  the  subject.  A 
pre-medical  department, —  Jefferson  Park  Academy, —  recruited  by  solicitors,  has 
been  organized  by  way  of  feeding  the  medical  school.  A  vigorous  advertising  and 
soliciting  system  is  operated. 

Attendance :  181 ;  about  one-half  from  Illinois. 
Teaching-  staff':  42,  of  whom  21  are  professors. 
Resources  available  for  maintenance :  Fees,  amounting  to  $19,380  (estimated). 

Laboratory  facilities :  The  school  building  is  in  wretched  condition.  One  badly  kept 
room  is  devoted  to  anatomy ;  it  contained  a  few  cadavers  as  dry  as  leather;  another, 
in  similar  condition,  is  given  to  chemistry.  There  is  slight  provision  for  pathology 
and  bacteriology;  equipment  for  physiology  is  sufficient  only  for  simple  demon- 
strations. There  are  no  teaching  accessories  worthy  of  mention. 

Clinical  faculties :  These  comprise  a  pay  hospital  of  45  beds,  in  which  it  is  claimed 
that  20  are  made  available  for  teaching  use  by  means  of  free  medical  (not  hospi- 
tal) services ;  and  two  places  on  the  Cook  County  Hospital  staff.  The  clinical  facili- 
ties are  utterly  inadequate. 
There  is  a  small  dispensary. 


ILLINOIS  211 

The  institution  is  frankly  commercial.  Its  change  of  name  (dropping  "eclectic")  is 
a  business  move. 

Date  of  visit:  April,  1909. 

(6)  AMERICAN  MEDICAL  MISSIONARY  COLLEGE.  Organized  1895.  This  school  gives  the 
bulk  of  its  instruction  at  Battle  Creek,  Michigan,  which  see  for  complete  account. 

(7)  JENNER  MEDICAL  COLLEGE.  Organized  1892.  A  night  school,  occupying  three 
upper  floors  of  a  business  house.  An  independent  institution. 

Entrance  requirement:  Nominal  compliance  with  state  law.  A  one-year  pre-medical 
class  is  operated  by  way  of  satisfying  the  law. 

Attendance:  112. 

Teaching  staff:  37,  of  whom  28  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $12,880  (estimated). 

Laboratory  facilities :  The  equipment  consists  of  a  meager  outfit  for  chemistry,  a 
somewhat  better  equipment  for  physiology,  though  no  animals  were  to  be  seen, 
and  a  slight  outfit  for  pathology  and  bacteriology.  Anatomy  is  taught  by  lectures 
"with  the  cadaver"  from  the  beginning  of  the  year  until  May  15,  after  which 
there  is  "dissecting  until  the  close  of  the  year." 

Clinical  facilities :  Clinical  facilities  are  practically  nil, — one  or  two  night  clinics 
being  all  that  the  school  claims  to  offer.  The  school  once  had  access  to  Grace 
Hospital,  a  private  institution  of  30  beds;  but  it  has  recently  been  turned  out  for 
failure  to  pay  for  the  privilege. 

The  dispensary  attendance  varies  from  two  to  ten,  four  nights  weekly.  No  par- 
ticular rooms  for  dispensary  purposes  are  provided:  "patients  are  taken  right  into 
the  rooms  where  the  classes  are." 

An  out-and-out  commercial  enterprise.  The  instruction  is  plainly  a  quiz-compend 
drill  aimed  at  the  written  examinations  set  by  the  state  board  of  Illinois  and  of 
other  states.  The  possibility  of  teaching  medicine  acceptably  in  a  night  school  is 
discussed  below  (p.  216,  note). 
Date  of  visit:  April,  1909. 

(8)  ILLINOIS  MEDICAL  COLLEGE.  Organized  1894.  ) 

(9)  RELIANCE  MEDICAL  COLLEGE.  Organized  1907.J 

These  two  schools  are  bracketed  because  they  are  only  different  aspects  of  one  en- 
terprise worked  in  two  shifts,  one  body  of  students  attending  by  day,  the  other  by 
night.  The  plant  is  thus  in  "continuous  performance."  It  is  owned  by  its  president, 
who  is  in  the  main  assisted  in  the  scientific  branches  by  recent  college  graduates, 
to  whom  small  sums  are  paid ;  in  the  clinical  branches  by  young  physicians  who 


212  MEDICAL  EDUCATION 

tender  their  services  gratis  in  order  to  "work  up  their  business."  The  day  school  is 
affiliated  with  Loyola  University. 

Entrance  requirement:  Of  the  kind  usual  in  Illinois  commercial  medical  schools.  A 
pre-medical  class,  running  three  hours  each  night,  covers  in  one  year  the  work  of 
two  high  school  years.  A  boy  who  is  engaged  all  day  in  trade  can  thus  "finish" 
two  years'  English,  Latin,  and  mathematics  at  night  in  a  single  session.  It  is  prob- 
able that  the  pre-medical  course  will  be  lengthened  to  two  such  years,  "equiva- 
lent" to  an  entire  high  school  course  according  to  the  "Illinois  idea." 

Attendance:  Reliance  Medical  College,  83;  Illinois  Medical  College,  69. 

Teaching  staff:  The  night  medical  school  (Reliance)  has  a  faculty  of  44,  23  being  pro- 
fessors ;  the  day  branch  (Illinois  Medical)  has  a  faculty  of  73,  38  being  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $9945  (Reliance,  estimated); 
$9175  (Illinois,  estimated). 

Laboratory  facilities:  The  equipment  conforms  to  legal  stipulations:  there  is  a  library, 
the  beginnings  of  a  museum,  an  ordinary  dissecting-room,  a  small  amount  of  ap- 
paratus for  physiology,  and  fair  laboratories,  as  things  go,  for  chemistry,  histology, 
pathology,  and  bacteriology.  The  laboratories  are  in  good  condition  and  are  really 
used. 

Clinical  facilities.  Day  students:  Some  eight  or  ten  hours  weekly  for  junior  and  senior 
classes  in  scattered  hospitals;  work  almost  wholly  surgical;  one  to  two  hours  daily 
in  the  dispensary  in  the  college  building.  Students  see  no  contagious  diseases; 
obstetrical  work  is  all  out-patient.  Night  students:  About  six  hours  weekly  at  the 
Cook  County  Hospital  between  6.30  and  9.30  p.m.,  opportunities  being  limited 
to  looking  on  at  surgical  work;  dispensary,  nightly.  The  night  students  see  no 
children's  diseases,  no  acute  medical  diseases  at  the  bedside,  no  contagious  diseases. 

Datet  of  visit*. •  April,  1909;  December,  1909. 

(10)  NATIONAL  MEDICAL  UNIVERSITY.  A  night  school,  organized  in  1891  as  "homeo- 
pathic," which  word  was  subsequently  dropped.  Ostensibly  the  medical  depart- 
ment of  the  "Chicago  Night  University,"  which  claims  departments  of  arts,  law, 
dentistry,  pharmacy,  etc.  The  school  appears  to  be  owned  by  the  "dean." 

Entrance  requirement:  Entrance  is  on  the  same  basis  as  in  other  night  schools;  a 
"preparatory  department"  is  also  in  operation. 

Attendance:  150.  "Free  transportation  from  Chicago  to  Vienna  by  way  of  New  York, 
London,  Paris,"  etc.,  is  offered  to  any  graduate  who  has  for  "three  years  or  more 
paid  regular  fees  in  cash." 

Teaching  staff:  36. 

Resources  available  for  maintenance:  Fees,  amounting  to  $22,500  (estimated). 


ILLINOIS  213 

Laboratory  facilities;  The  school  occupies  a  badly  lighted  building,  containing  no- 
thing that  can  be  dignified  by  the  name  of  equipment.  There  had  been  no  dissecting 
thus  far  (October  to  the  middle  of  April),  anatomy  being  didactically  taught. 
Persistent  inquiry  for  the  "dissecting-room"  was,  however,  finally  rewarded  by 
the  sight  of  a  dirty,  unused,  and  almost  inaccessible  room  containing  a  putrid 
corpse,  several  of  the  members  of  which  had  been  hacked  off.  There  is  a  large 
room  called  the  chemical  laboratory,  its  equipment  "locked  up,""  the  tables  spot- 
less. "About  ten"  oil-immersion  microscopes  are  claimed — also  "locked  up  in  the 
storeroom."  There  is  not  even  a  pretense  of  anything  else.  Classes  in  session 
were  all  taking  dictation. 

Clinical  facilities:  The  top  floor  is  the  "hospital:"  it  contained  two  lonely  patients. 
Access  to  a  private  hospital  two  miles  distant  is  also  claimed. 

Recently  this  school  has  been  declared  by  the  Illinois  State  Board  of  Health  as  "not 
in  good  standing."  The  same  action  was  taken  once  before,  but  was  afterwards  re- 
voked; just  why,  it  is  impossible  to  find  out;  for  the  school  was  after  the  revoca- 
tion just  exactly  what  it  was  at  the  time  of  its  suspension;  and  it  is  the  same 
to-day. 
Date  of  visit:  April,  1909. 

(11)  COLLEGE  OF  MEDICINE  AND  SURGERY:  PHYSIO- MEDICAL.  Organized  1885.  An 
independent  school. 

Entrance  requirement:  Such  as  satisfies  the  present  interpretation  of  the  law.  A  dili- 
gent search  in  the  office  desk  and  safe  failed  to  discover  any  credentials  of  students 
now  in  the  school. 

Attendance:  33. 

Teaching  staff':  42,  of  whom  33  are  professors. 

Resources  available  for  maintenance:  The  school  has  no  resources  but  fees,  amounting 
to  $2935  (estimated). 

Laboratory  facilities :  The  equipment  is  very  meager. 

Clinical  facilities:  Clinical  facilities  amount  to  little:  there  were  in  the  hospital  last 
year  167  patients,  over  one-half  surgical;  there  is  an  annual  attendance  of  250  in 
the  dispensary. 

Date  of  visit:  April,  1909. 

(12)  HERING  MEDICAL  COLLEGE.  Homeopathic.  Organized  1892.  This  school  teaches 
homeopathic  doctrine  in  its  original  purity. 

Entrance  requirement:  "High  school  or  equivalent." 
Attendance:  32. 


214  MEDICAL  EDUCATION 

Teaching  staff:  44,  of  whom  30  are  professors. 

Resources  available  for  maintenance :  Fees,  amounting  to  $3360  (estimated). 

Laboratory  facilities :  The  equipment  is  very  meager. 

Clinical  facilities :  These  are  very  limited.  Students  are  not  admitted  to  the  adjoining 

hospital.  There  is  a  small  dispensary. 
Daitofvirit:  April*  1909. 

(13)  HAHNEMANN  MEDICAL  COLLEGE.  Homeopathic.  Organized  1859.  An  indepen- 
dent institution. 

Entrance  requirement :  "  High  school  or  equivalent." 

Attendance  :130. 

Teaching  staff:  84,  of  whom  38  are  professors. 

Resources  available  for  maintenance :  Fees,  amounting  to  $14,300  (estimated). 

Laboratory  facilities :  The  school  occupies  a  building  wretchedly  dirty,  excepting  only 
the  single  laboratory,  fairly  equipped,  devoted  to  pathology  and  bacteriology.  The 
equipment  covers  in  a  meager  way  also  anatomy,  physiology,  histology,  chemistry. 

Clinicalfacilities :  In  the  adjoining  hospital  there  are  accommodations  in  the  wards  for 
60  beds,  but  there  are  no  ward  clinics.  The  superintendent  is  a  layman  who  "  does 
not  believe  in  admitting  students  to  the  wards.  There  is  no  regular  way  for  them 
to  see  common  acute  diseases,"  as  only  amphitheater  clinics  are  held.  Hospital  in- 
ternes do  all  the  obstetrical  work  ;  students  "  look  on."  The  school  also  holds  two 
appointments  on  the  surgical  side  in  the  Cook  County  Hospital. 
There  is  a  fair  dispensary. 

Date  ofvitit :  April,  1909. 

(14)  LITTLEJOHN  COLLEGE  OF  OSTEOPATHY.  An  undisguised  commercial  enterprise. 
Entrance  requirement:  Nominal. 

Attendance:  75. 

Teaching  staff:  43. 

Resources  available  for  maintenance :  Fees,  and  income  from  patients. 

Laboratory  facilities :  Practically  none.  At  the  time  of  the  visit,  some  rebuilding  was 
in  progress,  in  consequence  of  which  even  such  laboratories  as  are  claimed  were, 
except  that  of  elementary  chemistry,  entirely  out  of  commission  and  likely  to  re- 
main so  for  months :  but  "  teaching  goes  on  all  the  same."  Class-rooms  were  prac- 
tically bare,  except  for  chairs  and  a  table. 

Clinical  facilities  .-The  Littlejohn  Hospital, — a  pay  institution  of  20  beds,  mostly  sur- 


ILLINOIS  215 

gical, —  which  can  be  of  little  use.  It  was  claimed,  too,  that "  medicine  and  surgery 
are  taught  in  the  school,"  and  color  is  lent  to  the  statement  by  the  presence  on 
the  faculty  of  physicians  teaching  materia  medica,  etc. 
Date  of  visit:  December,  1909. 

(15)  THE  POSTGRADUATE  MEDICAL  SCHOOL  AND  HOSPITAL.  A  stock  company. 
Teaching  staff:  98. 

Resources  available  for  maintenance :  Fees. 

Laboratory  facilities :  A  good  working  clinical  laboratory. 

Clinical  facilities :  The  school  offers  clinical  instruction  in  its  own  hospital,  containing 
a  small  number  of  beds,  and  in  other  Chicago  institutions.  The  instruction  is  at- 
tended by  physicians  for  periods  varying  from  a  few  weeks  to  a  year. 

Date  of  visit:  April,  1909. 

(16)  CHICAGO  POLYCLINIC.  A  postgraduate  institution  organized  as  a  stock  company. 
Offers  special  courses  to  graduated  physicians. 

Attendance:  Perhaps  30  at  any  given  time;  a  total  of  350  in  the  course  of  a  year. 
Teaching  staff:  92,  30  being  professors,  62  of  other  grade. 
Resources  available  for  maintenance :  Fees. 

Laboratory  facilities :  A  small  clinical  laboratory,  the  instruction  in  technique  being 
given  by  a  first-year  student  in  one  of  the  night  schools ;  in  the  absence  of  the 
instructor,  he  also  conducts  classes. 

Clinical  facilities :  The  main  reliance  is  the  Polyclinic  Hospital  of  80  beds,  two-thirds 

of  them  surgical. 
Date  of  visit:  December,  1909. 

(17)  CHICAGO  EAR,  EYE,  NOSE,  AND  THROAT  COLLEGE.  A  stock  company  offering 
courses  in  certain  specialties. 

Attendance:  20  on  average;  average  period  of  residence,  two  months;  a  few  remain 
six  to  twelve  months. 

Teaching  staff:  22. 

Resources  available  for  maintenance:  Fees. 

Facilities:  A  fairly  equipped  dispensary  with  a  daily  attendance  of  15  to  20  new 
patients;  a  hospital  with  10  ward  beds,  empty  at  time  of  visit,  "but  full  a  week 
ago.1"  The  work  is  all  immediately  practical;  there  are  no  facilities  for  fundamen- 
tal or  intensive  instruction  or  effort. 

Date  of  visit :  December,  1909. 


216  MEDICAL  EDUCATION 

(18)  ILLINOIS  POSTGRADUATE  SCHOOL.  A  stock  company. 

Entrance  requirement:  The  M.D.  degree. 

Attendance:  6  to  8  at  any  given  time. 

Teaching  staff':  86,  of  whom  26  are  professors,  10  of  other  grade. 

Resources  available  for  maintenance:  Fees. 

Laboratory  facilities:  Practically  none. 

Clinical  facilities:  The  school  offers  courses  at  the  West  Side  Hospital,  a  private  in- 
stitution of  86  beds  occupied  mostly  by  surgical  cases.  There  is  a  large  dispensary. 
Date  ofvitit:  December,  1909. 

General  Considerations 

THE  city  of  Chicago  is  in  respect  to  medical  education  the  plague  spot  of  the  country. 
The  state  law  is  fairly  adequate,  for  it  empowers  the  board  of  health  to  establish  a 
standard  of  preliminary  education,  laboratory  equipment,  and  clinical  facilities,  thus 
fixing  the  conditions  which  shall  entitle  a  school  to  be  considered  reputable.  In  pur- 
suance of  these  powers,  the  board  has  made  the  four-year  high  school  or  its  equivalent 
the  basis,  and  has  enumerated  the  essentials  of  the  medical  course,  including,  among 
other  things,  clinical  instruction  through  two  annual  terms. 

With  the  indubitable  connivance  of  the  state  board,  these  provisions  are,  and  have 
long  been,  flagrantly  violated.  Of  the  fourteen  undergraduate  medical  schools  above 
described,  the  majority  exist  and  prepare  candidates  for  the  Illinois  state  board  ex- 
aminations in  unmistakable  contravention  of  the  law  and  the  state  board  rules. 
These  schools  are  as  follows :  (1)  Chicago  College  of  Medicine  and  Surgery  (Valpa- 
raiso University),  (2)  Hahnemann  Medical  College,  (3)  Hering  Medical  College,  (4) 
Illinois  Medical  College,  (5)  Bennett  Medical  College,  (6)  Physio-Medical  College  of 
Medicine  and  Surgery,  (7)  Jenner  Medical  College,  (8)  National  Medical  University, 
(9)  Reliance  Medical  College,  (10)  Littlejohn  College  of  Osteopathy.  Of  these,  only 
one,  the  National  Medical  University,  has  been  deprived  of  "good  standing "  by 
the  state  board.  Without  exception,  a  large  proportion  of  their  attendance  offers  for 
admission  an  "  equivalent,"  which  is  not  an  equivalent  in  any  sense  whatsoever ;  it 
is  nevertheless  accepted  without  question  by  the  state  board,  though  the  statute  ex- 
plicitly states  that  it  can  exact  an  equivalent  by  "  satisfactory  "  examination.  In  the 
case  of  the  night  schools,1  for  instance,  one  or  two  years'  requirements  are  satisfied 

1  Even  supposing  the  night  schools  enforced  an  entrance  standard  and  actually  provided  laboratories 
and  hospitals  of  the  right  kind,  the  teaching  of  anything  but  didactic  medicine  at  night  is  practically 
impossible,  because  :  (1)  The  time  is  too  limited.  The  day  school  is  in  operation  all  day  long  and  the 
student  has  his  evenings  for  study ;  the  night  school  can  at  most  secure  three  or  four  hours  when  the  stu- 
dent is  already  physically  fatigued.  (2)  Laboratory  work  by  artificial  light  is  bound  to  be  unsatisfac- 
tory, even  if  the  lighting  is  good,  which  is  not  usually  the  case.  (3)  Hospital  clinics,  operations,  etc., 
must  be  very  limited  at  night,  when  the  interest  of  the  patient  requires  that  he  be  allowed  to  rest. 
Children's  diseases  cannot  be  studied  at  night  at  all.  (4)  The  situation  is  rendered  even  more  absurd 
by  the  fact  that,  in  addition  to  all  these  handicaps,  the  night  school  student  frequently  has  to  make 
up  some  conditions  in  preliminary  studies. 


ILLINOIS  217 

by  "  coaching  "  one  night  a  week  in  each  of  the  several  subjects  :  one  evening  is  de- 
voted to  Latin,  the  next  to  English,  the  next  to  mathematics.  There  is  absolutely 
no  guarantee  that  the  candidate  accepted  on  the  equivalent  basis  has  had  an  educa- 
tion even  remotely  resembling  the  high  school  training  which  the  Illinois  law  intends 
as  the  minimum  upon  which  it  will  recognize  a  candidate  for  the  physician's  license. 
If  the  state  board  should — as  in  duty  bound — publicly  brand  these  schools  as  "not 
in  good  standing"  by  reason  of  their  failure  to  require  a  suitable  preliminary  educa- 
tion of  their  students,  their  graduates  would  be  immediately  excluded  from  practice 
in  Illinois ;  adjoining  states  would  rapidly  follow  suit,  with  the  result  that  the  schools 
would  shortly  be  exterminated.  Fortunately,  the  case  against  them  does  not  rest  alone 
on  the  question  of  entrance  requirements :  for  not  a  single  one  of  the  schools  men- 
tioned furnishes  clinical  opportunities  in  proper  abundance,  and  some  of  them  even 
fail  to  provide  the  stipulated  training  in  other  branches,  e.  g.,  anatomy.  An  efficient 
and  intelligent  administration  of  the  law  would  thus  reduce  in  short  order  the  medi- 
cal schools  of  Chicago  to  three,  Rush,  Northwestern,  and  the  College  of  Physicians 
and  Surgeons.1  In  the  matter  of  entrance  requirements,  Rush  alone  is  secure.  The 
College  of  Physicians  and  Surgeons  rests  on  the  high  school  or  equivalent  basis; 
if  a  scholastic  equivalent,  such  as  would  be  acceptable  to  the  academic  department 
of  the  state  university,  is  insisted  on,  the  registration  will  be  seriously  diminished. 
Northwestern  is  in  a  similar  plight:  it  requires  now  a  high  school  education  or 
equivalent,  followed  by  a  year  of  college  which  it  does  not  get.  If  its  standard  were 
enforced,  its  present  attendance  would  be  considerably  reduced.  At  both  Northwest- 
ern and  the  College  of  Physicians  and  Surgeons  the  inequality  and  incapacity  of  the 
present  student  body  are  frankly  conceded.  "The  facilities  are  better  than  the  stu- 
dents," said  a  professor  at  the  former;  "the  admission  machinery  doesn't  stop  the 
unfit,"  said  a  professor  at  the  latter.  That  both  these  schools  will  be  driven  by  in- 
ternal and  external  forces  to  a  higher  level,  actually  enforced,  is  inevitable.  When 
that  happens,  their  attendance  will  materially  shrink;  and  as  higher  standards  will 
check  the  invasion  of  medical  schools  by  drifting  waverers,  and  will  tend  to  keep  the 
number  of  doctors  in  more  nearly  normal  relation  to  the  needs  of  the  population,  it 
is  not  likely  that  either  school  will  again  attain  its  former  size.  This  consideration  is 
rendered  additionally  important  because  it  portends  a  marked  reduction  in  income 
through  fees,  upon  which  both  schools  still  depend. 

In  the  matter  of  teaching  facilities,  the  three  schools  under  discussion  satisfy  the 
law ;  but  they  satisfy  the  aspirations  of  their  faculties  only  in  varying  degrees.  The 
scientific  work  of  the  University  of  Chicago,  relied  on  by  Rush,  is  excellent;  the  pro- 
vision made  by  Northwestern  and  the  College  of  Physicians  and  Surgeons  is  distinctly 
inferior  to  it.  Assuming  that  Northwestern  will  rise  to  an  actual  one  or  two  year 
college  basis,  it  must  provide  correspondingly  increased  facilities  both  for  the  higher 
grade  students  and  for  the  more  productive  teaching  body  which  these  students  will 
aFor  the  American  Medical  Missionary  College,  see  "Michigan." 


218  MEDICAL  EDUCATION 

demand.  There  are,  for  instance,  several  full-time  instructors,  but  they  are  without 
an  adequate  force  of  assistants.  The  needs  of  the  College  of  Physicians  and  Surgeons 
are  much  greater.  Its  laboratory  facilities  and  equipment  are  inadequate  even  for  the 
present  student  body ;  and  it  has  barely  begun  the  development  of  a  full-time  teach- 
ing staff  in  the  scientific  branches.  Both  these  schools  face  an  era  of  increased  in- 
vestment in  plant  and  of  considerably  augmented  running  expenses,  coinciding  with 
a  period  of  reduced  income  from  tuition  fees. 

On  the  clinical  side,  Rush  and  Northwestern  do  not  differ  substantially ;  the  College 
of  Physicians  and  Surgeons  is  somewhat  inferior.  Both  Rush  and  Northwestern  have 
an  exclusive  staff  connection  with  certain  hospitals.  Their  hospital  situation  is  there- 
fore, as  things  go  in  this  country,  tolerable.  They  command  a  sufficient  number  of 
cases,  subject,  however,  to  two  defects  that  will  be  more  acutely  felt  as  clearer  ideals 
become  dominant  in  medical  education :  (1)  they  are  not  in  position  freely  to  import 
clinical  teachers,  nor  (2)  can  they  in  general  discontinue  a  professorial  appointment 
without  to  the  same  extent  abridging  their  clinical  resources;  none  of  them  completely 
controls,  even  in  a  single  hospital,  the  conditions  under  which  clinical  instruction  is 
given.1 

The  Cook  County  Hospital  is  common  to  all  three.  Its  relations  to  the  medical 
schools  have  been  subject  to  variation  and  disturbance.  The  institution  is  con- 
ducted by  a  lay  warden,  who,  though  a  politician,  is  now  friendly  to  the  schools. 
At  present,  the  staff  is  selected  by  civil  service  examination  every  six  years.  Rush 
now  holds  twice  as  many  appointments  as  either  of  the  other  two  schools,  a  discre- 
pancy that  may  be  either  emphasized,  obliterated,  or  reversed  at  the  next  examina- 
tion. The  main  clinical  facilities  of  the  several  schools  are  thus  precarious.  They  are 
also  limited:  a  recent  unpleasantness — due,  according  to  one  version,  to  a  quarrel 
between  certain  doctors  and  some  nurses  who  objected  to  the  careless  way  in  which 
the  doctors  replaced  the  bed  sheets — has  resulted  in  the  exclusion  of  students  from 
the  wards.  Patients  are  exhibited  in  rooms.  The  incident  involves  serious  limitations 
upon  teaching  methods,  and  illustrates  the  uncertainty  which  attaches  to  mere  privi- 
leges and  courtesies.  Cases  cannot  be  assigned  for  intensive  study  to  particular  stu- 
dents; hospital  residents  make  the  records  and  do  the  clinical  laboratory  work.  The 
undergraduate  student  can  see  conditions  in  abundance;  he  cannot  at  close  range 
observe  processes  in  development.  The  Cook  County  Hospital  is  therefore,  from  a 
strictly  educational  point  of  view,  not  a  laboratory  in  which  beginners  can  be  trained 
in  a  thorough  technique.  It  is,  however,  immensely  valuable  as  a  storehouse  of 
illustrative  material  for  students  who  have  elsewhere  received  a  satisfactory  prelimi- 
nary discipline. 

None  of  the  supplementary  hospitals  used  by  the  schools  cures  these  defects.  They 

1  Rush  comes  nearest  to  desirable  conditions  at  Presbyterian  Hospital,  for  staff  appointments  there 
are  by  contract  completely  controlled  by  its  faculty.  But  it  is  provided  that  "no  patient  shall  be  made 
the  subject  of  clinical  instruction  without  his  or  her  consent. 


ILLINOIS  219 

are  too  small;  their  purpose  is  only  secondarily  educational;  friction  is  liable  to  arise 
over  efforts  to  retain  patients  for  teaching  purposes;  the  students  remain  more  or 
less  outsiders. 

The  modernization  of  medical  education  in  Chicago  requires,  then,  that  two  of 
the  three  schools  in  question  should  greatly  strengthen  their  laboratory  instruction, 
and  that  all  three  should  strengthen  their  clinical  instruction.  The  number  of  stu- 
dents to  be  provided  for  is  a  factor  in  determining  a  definite  line  of  procedure.  Rush 
has  on  its  two-year  college  basis  488  students;  Northwestern  had  in  its  first-year 
class,  on  a  very  loosely  enforced  one-year  college  basis,  66;  the  inevitable  two-year 
standard  will  greatly  reduce  this  number.  Should  the  College  of  Physicians  and  Sur- 
geons go  to  the  two-year  college  standard, — an  inevitable  development  if  it  lives, — 
it  would  suffer  similarly.  It  seems  fair  to  estimate,  then,  that  the  actual  number  of 
medical  students  in  Chicago  on  a  two-year  college  basis  will  not  be  too  large  to  be 
cared  for  in  a  single  school  adequately  equipped  with  laboratories  and  hospital. 
As  medical  education  on  the  proper  basis  cannot  be  attempted  outside  a  university, 
and  as  none  of  the  three  universities  now  teaching  medicine  in  Chicago  is  likely  to 
abandon  the  field  to  the  others,  it  is  suggested  in  the  interest  of  efficiency  and  eco- 
nomy that  (1)  each  of  the  three  universities  continue  to  provide — like  the  University 
of  Chicago — the  instruction  of  the  first  two  years;  (2)  all  three  universities  combine 
to  form  a  clinical  department  under  joint  management,  the  first  step  towards  which 
would  be  a  concerted  effort  to  procure  a  proper  hospital  for  the  use  of  third  and 
fourth  year  men.  The  sum  necessary  to  procure  three  such  hospitals  is  so  large  that 
it  is  highly  improbable  that  as  separate  institutions  the  schools  can  acquire  sepa- 
rate and  adequate  clinical  departments.  Inasmuch  as  there  is  no  demand  for  gradu- 
ates exceeding  the  capacity  of  one  clinical  school,  it  would  be  sheer  extravagance  to 
equip  three  on  the  basis  proposed.  The  Cook  County  and  other  hospitals  would,  on 
the  suggested  arrangement,  play  the  part  for  which  they  are  exactly  suited  in  fur- 
nishing illustrative  material  for  advanced  students  whose  discipline  had  been  else- 
where looked  to,  and  in  making  possible  the  development  of  instruction  for  gradu- 
ates in  all  the  specialties, — a  form  of  opportunity  for  which,  just  for  lack  of  differ- 
entiation and  organization,  our  physicians  are  still  forced  to  go  abroad.  A  great 
opportunity  is  thus  fairly  within  the  grasp  of  Chicago :  the  conditions  to  its  realiza- 
tion are  honesty  and  intelligence  on  the  part  of  the  state  authorities,  and  cooperation 
between  the  three  great  universities  of  the  state.  The  execution  of  this  plan  might 
set  the  country  at  large  to  thinking  on  the  wisdom  and  necessity  of  coordinating  our 
educational  enterprises.  Everywhere,  thus  far,  our  higher  education  has  worn  a  com- 
petitive aspect.  Some  good  has  been  thus  accomplished;  but  now  that  local  or  nu- 
merical competition  can  be  replaced  by  scientific  and  scholarly  competition,  to  which 
the  entire  country  and  indeed  the  civilized  world  are  parties,  we  begin  to  realize  the 
waste  and  demoralization  due  to  institutional  competition.  It  is  difficult  to  see  how 
the  state  of  Illinois,  which  in  the  interest  of  public  health  ought  to  be  a  factor  in 


220  MEDICAL  EDUCATION 

medical  education,  can  make  an  effective  contribution  thereto  except  by  cooperation 
with  the  Chicago  schools.  Should  the  state  seek  to  develop  its  own  school  in  Chicago 
with  the  inevitable  low  tuition  fees,  great  friction  must  result.  Much  preferable  to 
conflict  would  be  the  withdrawal  of  the  state  from  participation  in  clinical  instruc- 
tion altogether,  content  in  that  event  with  a  half-school  at  Urbana,  strengthened, 
be  it  hoped,  by  state  laboratories  of  public  health.  The  entire  situation  presents 
a  rare  opportunity  for  educational  statesmanship. 

INDIANA 

Population,  2,808,115.  Number  of  physicians,  5,036.  Ratio,  1 :  558. 
Number  of  medical  schools,  2. 

BLOOMINGTON-INDIANAPOLIS:  (Population:  Bloomington,  8,902;  Indian- 
apolis, 249,426). 

(1)  INDIANA  UNIVERSITY  SCHOOL  OF  MEDICINE.  Started  at  Bloomington,  1908,  it  first 
gave  two  years'  work  at  Bloomington,  1905,  and  the  entire  course  at  Indianapolis, 
1909,  through  absorption  of  the  local  school.  The  double  department  is  an  organic 
part  of  the  state  university. 

Entrance  requirement;  One  year  of  college  work. 
Attendance:  266,  94  per  cent  from  Indiana. 

Teaching  staff:  175,  of  whom  99  are  professors.  The  laboratory  branches  at  Bloom- 
ington are  taught  by  full-time  teachers,  some  of  whom  will  for  a  while  divide 
their  time  between  Indianapolis  and  Bloomington.  The  Indianapolis  teachers  are 
otherwise  all  practitioners. 

Resources  available  for  maintenance:  Both  departments  will  be  hereafter  supported 
out  of  the  general  funds  of  the  university,  as  the  Bloomington  department  has 
hitherto  been,  — at  a  heavy  loss,  of  course.  Fees  (amounting  at  Indianapolis  and 
Bloomington  together  to  $31,240)  are  paid  into  the  university  treasury. 

Laboratory  facilities :  At  Bloomington  separate  laboratories  with  good  equipment 
are  provided  for  pathology  and  bacteriology,  physiology  and  pharmacology,  and 
anatomy, — the  last-named  strong  in  histology  and  neurology.  Embryology  is 
taught  in  the  department  of  biology,  physiological  chemistry  in  the  department 
of  chemistry.  Books  and  periodicals  are  accessible. 

At  Indianapolis  the  laboratories  of  the  absorbed  school  were  limited,  but  the 
university  has  already  taken  some  steps  to  bring  them  up  to  the  level  of  the  Bloom- 
ington department. 

Clinical  facilities :  Clinical  instruction  will  be  given  at  Indianapolis  alone.  The  city 
dispensary  is  under  control  of  the  school  faculty  and  has  just  been  placed  in  charge 


INDIANA  221 

of  a  man  of  modern  training.  The  attendance  has  been  good.  The  City  Hospital 
staff  is  appointed  by  the  board  of  health  on  nomination  of  the  university.  The 
facilities  are  fair,  but  they  have  been  used  to  little  advantage  in  the  past.  There 
is  no  pavilion  for  contagious  diseases. 
Date  of  visit:  December,  1909. 

VALPARAISO:  Population,  6280. 

(2)  VALPARAISO  UNIVERSITY.  This  institution  offers  first  two  years  at  Valparaiso  and 
all  four  in  Chicago.  (See  Chicago  College  of  Medicine  and  Surgery.)  The  two-year 
department  was  organized  in  1901. 

Entrance  requirement:  A  high  school  course  or  its  equivalent. 
Attendance:  25. 

Teaching  staff:  Two  instructors  conduct  the  classes  in  physiology,  pathology,  bac- 
teriology, and  anatomy,  in  the  medical  building.  Chemistry,  materia  medica,  and 
pharmacy  are  taught  by  men  who  give  courses  in  these  same  branches  to  other 
students.  The  pathologist  spends  one-third  of  his  time  in  the  Chicago  depart- 
ment. 

Resources  available  for  maintenance:  Fees  only. 

Laboratory  facilities :  There  is  a  simple  but  good  equipment  for  teaching  the  neces- 
sary branches  in  an  elementary  form,  pathology  being  perhaps  the  weakest  by 
reason  of  the  small  amount  of  gross  material  available.  The  time  of  the  teachers 
is  consumed  in  routine  work. 

Date  of  visit :  December,  1909. 

General  Considerations 

THE  situation  in  the  state  is,  thanks  to  the  intelligent  attitude  of  the  university, 
distinctly  hopeful,  though  it  will  take  time  to  work  it  out  fully.  The  university 
has  just  secured  complete  control  of  the  Indianapolis  school.  The  state  board  has 
already  come  to  its  help  by  making  the  two-year  college  standard,  in  force  at  the 
university  in  1910,  the  legal  minimum  for  practice  within  the  state.  This  places  medi- 
cal education  in  Indiana,  as  it  already  is  in  Minnesota,  in  the  hands  of  the  state  uni- 
versity. The  Bloomington  department  has  been  of  such  a  character  that  it  was  easily 
possible  to  make  it  worthy  of  college-bred  students,  but  the  detachment  of  its  teachers 
for  regular  service  at  Indianapolis  should  not  long  continue.  While  it  is  highly  im- 
portant that  close  relations  be  encouraged,  it  is  necessary  to  accomplish  this  by  pro- 
gressively strengthening  the  Indianapolis  end. 

The  Indianapolis  school  has  been  of  the  ordinary  local  type  of  the  better  sort. 
In  order  to  make  the  school  attractive  to  highly  qualified  students,  it  will  be  neces- 
sary (1)  to  employ  full-time  men  in  the  work  of  the  first  two  years,  (2)  to  strengthen 


222  MEDICAL  EDUCATION 

the  laboratory  equipment,  (3)  greatly  to  improve  the  organization  and  conduct  of 
the  clinical  courses.  The  trustees  have  formally  committed  themselves  to  this  policy. 
It  would  appear  necessary  for  some  years  to  regard  the  needs  of  the  Indianapolis 
department  as  a  first  lien  on  the  increasing  income  of  the  university,  if  the  univer- 
sity is  to  make  good  the  ideals  indicated  by  its  entrance  requirement.  It  can  do  Indi- 
ana no  greater  service  in  any  direction.  That  done,  Indiana  will  be  one  of  the  few 
states  that  have  successfully  solved  the  problem  of  medical  education. 


IOWA 

Population,  2,192,608.  Number  of  physicians,  3,624.  Ratio,  1 :  605. 
Number  of  medical  schools,  4. 

DES  MOINES:  Population,  89,113. 

(1)  DRAKE  UNIVERSITY  COLLEGE  OF  MEDICINE.  Organized  in  1882  as  an  independent 
school,  it  became  a  university  department  in  1900.1 

Entrance  requirement:  A  four-year  high  school  education. 
Attendance:  106. 

Teaching  staff:  16  professors  and  29  of  other  grade;  total,  45.  There  are  no  whole- 
time  teachers.  Student  assistants  are  employed  in  the  laboratories. 

Resources  available  for  maintenance:  The  school  is  practically  dependent  on  its  fees, 
the  volume  of  which  is  not  large, — for  the  funds  of  the  university  are  too  slender 
to  permit  any  considerable  allotment  to  the  medical  department.  The  total  budget 
of  the  department  was  $12,417,  of  which  $9505  came  from  student  fees,  $1239 
from  interest. 

Laboratory  facilities :  Modest  laboratories,  whose  condition  speaks  well  for  the  con- 
scientiousness of  those  in  charge,  are  provided  for  chemistry,  anatomy,  pathology, 
and  bacteriology.  The  provision  for  physiology  is  somewhat  more  slender. 

Clinical  facilities :  The  school  conducts  clinics  by  courtesy  at  two  hospitals,  where 
instruction  is  given  in  a  demonstrative  way  for  some  twelve  to  fifteen  hours  weekly. 
The  opportunities  are  in  every  respect  inadequate:  the  time  is  too  short,  the 
amount  of  material  available  too  little,  and  the  opportunities  open  to  students  too 
limited.  A  fair  amount  of  obstetrical  work  is  obtained. 

The  school  owns  and  controls  a  small  dispensary,  fairly  well  equipped  and 
painstakingly  conducted. 

Date  of  vint:  April,  1909. 

1  As  this  report  goes  to  press,  it  is  announced  that  a  fund  of  $100,000  has  been  subscribed  with  which 
to  improve  this  school. 


IOWA  223 

(2)  STILL  COLLEGE  OF  OSTEOPATHY.  Organized  1898.  An  independent  school. 
Entrance  requirement:  Less  than  a  common  school  education. 
Attendance:  115. 

Teaching  staff:  15,  of  whom  13  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $17,250  (estimated). 

Laboratory  facilities :  These  are  mainly  limited  to  signs.  "  Anatomy "  is  painted  pro- 
minently on  a  door  which,  on  being  opened, reveals  an  amphitheater ;  "Physiology** 
on  a  door  which,  on  being  opened,  reveals  a  class-room  with  an  almost  empty 
bookcase,  but  no  laboratory  equipment;  the  key  to  "Histology"  could  not  be  found; 
"Chemistry"  proved  to  be  a  disorderly  elementary  laboratory  with  some  slight  out- 
fit for  bacteriology  besides.  The  dissecting-room  was  inadequate  and  disorderly. 

Clinical  facilities :  The  school  makes  no  pretense  of  having  hospital  facilities.  The 
catalogue  states:  "Cases" — pay  cases  of  course — "needing  hospital  service  are 
placed  in  the  hospitals  of  the  city," — where  the  students  cannot  see  them.  The 
catalogue  says  of  the  infirmary:  "The  patient  in  no  way  comes  in  contact  with  the 
college  clinic." 

Everything  about  the  school  indicates  that  it  is  a  business.  One  is  therefore  not  sur- 
prised to  find  the  following  advertisement  in  the  local  newspaper:  "Have  your 
case  diagnosed  at  Still  College  of  Osteopathy,  1442  Locust  Street."  (Des  Moines 
Register  and  Leader,  Nov.  3,  1909.) 
Date  of  visit:  April,  1909. 

IOWA  CITY:  Population,  9007. 

(3)  STATE  UNIVERSITY  OF  IOWA  COLLEGE  OF  MEDICINE.  Organized  1869.  An  organic 
department  of  the  state  university. 

Entrance  requirement:  One  year  of  college  work. 
Attendance:  267,  87  per  cent  from  Iowa. 

Teaching  staff:  32,  of  whom  12  are  professors.  The  laboratory  instructors  devote 
full  time  to  their  work ;  the  clinical  teachers  are  practitioners,  some  of  them  non- 
resident :  the  professor  of  surgery  resides  at  Sioux  City,  the  professor  of  gyneco- 
logy,  who  is  likewise  dean  of  the  department,  at  Dubuque. 

Resources  available  for  maintenance:  The  department  is  supported  by  state  appro- 
priations. Its  income  from  fees  is  $13,707 ;  its  budget,  $35,216;  the  university  hos- 
pital budget  is  $33,745.  Chemistry,  general  expense  (light,  heat,  etc.),  and  a  share 
of  expense  of  general  administration  are  not  included  in  these  figures. 

Laboratory  facilities :  The  equipment  and  instruction  in  the  scientific  branches  are, 


224  MEDICAL  EDUCATION 

in  general,  good.  This  is  particularly  true  of  anatomy,  which  is  admirably  cared 
for.  The  departments  of  pathology  and  physiology  lack  a  sufficient  number  of 
skilled  assistants.  An  excellent  museum  and  books  are  at  hand. 

Clinical  facilities:  The  university  hospital  is,  as  it  now  stands,  too  small;  the  amount 
of  material  available  in  medicine,  obstetrics,  and  contagious  diseases  has  been  very 
limited.  An  appropriation  of  $75,000  has,  however,  been  made  for  the  purpose  of 
increasing  the  hospital  capacity.  The  methods  of  clinical  teaching  hitherto  pur- 
sued have  not  been  entirely  modern,  mainly  for  lack  of  proper  organization  and 
material.  Supplementary  clinical  material  is  obtainable  at  the  Sisters'  Hospital 
and  the  Tuberculosis  Sanitarium. 

The  dispensary  is  just  in  process  of  development.  The  dispensary  clinic  is  so  far 
largely  limited  to  the  eye,  ear,  nose,  and  throat. 

Latt  of  visit:  November,  1909. 

(4)  STATE  UNIVERSITY  OF  IOWA  COLLEGE  OF  HOMEOPATHIC  MEDICINE.  Organized  1877. 
An  organic  department  of  the  state  university. 

Entrance  requirement:  A  four-year  high  school  education. 
Attendance:  42,  83  per  cent  from  Iowa. 

Teaching  staff:  10  professors  and  15  of  other  grade.  The  professor  of  materia  medica 
and  therapeutics,  who  is  likewise  dean  of  the  department,  resides  at  Des  Moines, 
the  professor  of  theory  and  practice  at  Davenport. 

Resources  available  for  maintenance:  The  department  is  supported  by  state  appropri- 
ations. Its  income  from  fees  is  $1864,  its  budget  is  $5453,  its  hospital  budget  is 
$7847.  The  school  budget  does  not  include  expense  incurred  for  laboratory  in- 
struction for  a  reason  that  the  next  paragraph  will  explain. 

Laboratory  facilities :  Homeopathic  students  receive  their  laboratory  instruction  to- 
gether with  regular  students  of  medicine,  though  there  is  now  a  difference  of  one 
year  of  college  work  and  there  will  be  next  year  a  difference  of  two  such  years  in  their 
preparation,  unless  a  resolution  adopted  by  the  board  of  education  establishing  the 
same  basis  of  admission  in  the  two  departments  becomes  effective  before  that  time. 

Clinical  facilities:  The  department  possesses  a  hospital  of  35  beds,  quite  inadequate 
to  its  purpose.  The  dispensary  is  correspondingly  slender.  Operating  during  part 
of  last  year,  it  received  only  134  cases,  of  which  101  were  diseases  of  the  eye,  ear, 
nose,  and  throat. 

Date  ofvitit:  April,  1909. 

General  Considerations 

IOWA  is  a  state  in  which  there  are  now  between  two  and  three  times  as  many  doctors 
as  are  really  needed.  The  population  of  the  state  is  increasing  slowly,  if  at  all.  There 


KANSAS  225 

is,  then,  from  the  standpoint  of  the  public  interest  no  reason  why  a  great  number 
of  physicians  should  be  produced ;  there  is  no  reason  why  any  physician  should  be 
graduated  unless  his  entrance  into  the  profession  will  actually  improve  it.  Further 
dilution  would  be  unpardonable. 

Of  the  four  medical  schools  in  the  state  none  is  at  this  time  satisfactory.  The 
osteopathic  school  at  Des  Moines  is  a  disgrace  to  the  state  and  should  be  summarily 
suppressed.  In  the  absence  of  police  power  to  terminate  its  career  in  this  way,  its 
graduates,  undertaking  as  they  do  to  treat  all  sorts  of  diseases,  should  be  compelled 
to  meet  whatever  standards  are  applied  to  other  practitioners.  The  medical  depart- 
ment of  Drake  University  and  the  homeopathic  department  of  the  state  university 
are  well  intentioned  but  feeble  institutions  that  only  a  large  outlay  could  convert 
into  acceptable  and  efficient  schools.  Elevation  of  standards  will  probably  embarrass 
rather  than  aid;  for  the  urgent  necessity  of  additional  outlay  will  coincide  with  a  de- 
crease in  the  revenues  on  which  Drake,  at  least,  wholly  depends.  It  would  be  the  part 
of  wisdom  to  retire  from  a  contest  to  which  the  institution  is  clearly  unequal;  at  any 
rate,  it  ought  to  be  content  to  limit  its  endeavor  to  the  work  of  the  first  two  years. 

The  homeopathic  department  of  the  state  university  has  now  a  small  attendance 
on  a  relatively  low  entrance  basis.  As  its  students  receive  their  scientific  instruction 
with  the  classes  now  on  a  one-year,  and  hereafter  to  be  on  a  two-year,  college  basis, 
it  is  clear  that  the  entrance  standard  of  the  homeopathic  department  must  be  cor- 
respondingly elevated.  The  already  slender  enrolment  is  therefore  destined  still  further 
to  shrink.  For  so  small  a  body  of  students  the  state  is  not  likely  to  provide  increased 
clinical  facilities  and  a  resident  faculty  of  its  own.  Wisdom  would  therefore  counsel 
the  adoption  in  Iowa  of  the  Minnesota  plan :  the  two  medical  departments  of  the 
state  university  should  be  consolidated,  with  a  provision  for  special  teaching  in  ma- 
teria  medica  and  therapeutics  for  students  who  desire  the  homeopathic  diploma. 

The  two  university  hospitals  could  thus  be  added  together;  the  smaller  would 
perhaps  be  devoted  to  obstetrics;  the  larger,  with  the  additional  wing  now  to  be 
added,  would  provide  comfortably  for  general  medical  and  surgical  clinics.  The  cre- 
ation of  a  strong  resident  faculty,  and  the  adoption  of  a  liberal  and  enlightened 
policy  in  dealing  with  the  sick  poor  of  the  state,  would  place  Iowa  City  in  position 
to  duplicate  the  honorable  record  which  the  University  of  Michigan  has,  under  sim- 
ilar circumstances,  made  at  Ann  Arbor. 


KANSAS 

Population,  1,663,438.  Number  of  physicians,  2650.  Ratio,  1:  628. 
Number  of  medical  schools,  3. 

LAWRENCE-ROSED  ALE:  (Population:  Lawrence,  13,678;  Rosedale,  3270— 
suburb  of  the  two  Kansas  Cities,  population,  286,074). 


226  MEDICAL  EDUCATION 

(1)  UNIVERSITY  OF  KANSAS  SCHOOL  OF  MEDICINE.  The  Scientific  Department,  at  Law- 
rence, was  organized  in  1899;  the  Clinical  Department,  at  Rosedale,  was  organized 
by  merger  with  a  local  school  in  1905. 

Entrance  requirement:  Two  years  of  college  work. 
Attendance:  89,  79  from  Kansas,  8  from  Missouri. 

Teaching  staff:  At  Lawrence,  anatomy,  physiology,  and  bacteriology  are  taught  by 
teachers  whose  instruction  is  confined  to  medical  students;  but  the  professor  of 
anatomy  is  also  professor  of  gynecology  at  Rosedale  and  practises  his  specialty. 
The  pathologist  is  expected  to  eke  out  his  income  by  outside  work.  Physiology, 
chemistry,  and  pharmacy  are  taught  in  general  laboratories  devoted  to  those  sub- 
jects. The  medical  classes  are  not  always  separate. 

At  Rosedale  there  is  a  teaching  staff  of  63,  of  whom  24  are  professors.  Two  of 
them  devote  their  whole  time  to  teaching  pathology,  bacteriology,  and  clinical 
pathology.  A  third,  the  dean  of  this  end,  likewise  gives  his  entire  time  to  the 
school  and  hospital. 

Resources  available  for  maintenance:  The  medical  school  shares  in  the  general  funds 
of  the  university.  The  budget  for  the  current  year  is  about  $17,000  for  the  Sci- 
entific Department,  and  $23,000  for  the  Clinical  Department.  Income  in  fees, 
$5030. 

Laboratory  faculties :  The  laboratories  for  anatomy,  chemistry,  and  physiology  are 
good  and  in  active  operation.  Pathology  and  bacteriology  are,  so  far,  less  highly 
developed.  Books  and  current  scientific  periodicals  are  accessible. 

Clinical  facilities:  The  Clinical  Department  has  a  small  hospital  of  35  beds,  not 
used,  however,  to  the  best  advantage,  partly  because  the  faculty  is  not  composed 
of  men  whose  training  has  been  modern,  partly  because,  being  practitioners,  they 
cannot  devote  time  enough  to  teaching.  The  school  enjoys  additional  privileges 
of  the  usual  kind  at  a  Catholic  hospital  in  Kansas  City,  Kansas,  and  at  the  City 
Hospital  in  Kansas  City,  Missouri.  The  obstetrical  work  is  mainly  out-patient; 
contagious  diseases  are  rarely  seen.  On  the  whole,  far  too  little  clinical  material 
under  proper  control  is  offered.  An  excellent  building,  well  equipped,  devoted  to 
pathology,  clinical  pathology,  and  bacteriology,  adjoins  the  university  hospital.  It 
contains  a  few  books  and  some  current  periodicals. 

Two  dispensaries  are  available,  one  at  the  Rosedale  building,  not  used  for  teach- 
ing until  this  year;  the  other,  the  so-called  North  End  Dispensary,  where  a  fair 
amount  of  material  has  hitherto  been  handled  in  an  incredibly  slipshod  manner. 

Each  of  the  two  parts  of  the  university  school  of  medicine  has  its  own  dean ;  for  all 
practical  purposes,  the  university  conducts  two  half-schools. 
Dot*  ofvitit:  November,  1909. 


KANSAS  227 

(2)  WESTERN  ECLECTIC  COLLEGE  OF  MEDICINE  AND  SURGERY.  Organized  1898.  A 
stock  company. 

Entrance  requirement:  Nominal. 

Attendance:  21. 

Teaching  staff":  32,  of  whom  30  are  professors,  2  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  perhaps  $1600  this  year. 

Laboratory  facilities :  These  comprise  a  few  small,  indescribably  dirty  and  disorderly 
rooms,  containing  three  microscopes,  a  small  amount  of  physiological  apparatus, 
some  bacteriological  stains,  a  few  filthy  specimens,  and  meager  equipment  for  ele- 
mentary chemistry,  but  no  running  water.  All  laboratory  work  is  conducted  by  one 
teacher,  who  serves  in  the  same  capacity  in  the  local  osteopathic  and  homeopathic 
schools  and  does  commercial  work  besides.  No  anatomy  was  going  on  at  the  time 
of  the  visit,  as  dissection  runs  only  from  January  3  to  March  12. 

Clinical  facilities :  Practically  none.  A  wretched  room  is  called  the  "Dispensary," 
and  an  attendance  of  "about  three  a  day"  is  claimed;  it  is  hoped  that  this  "can 
be  worked  up  to  six  a  day."  The  catalogue  states  that  "clinics  are  held  weekly  at 
the  Kansas  City,  Missouri,  General  Hospital,"  but  the  statement  is  denied  by  the 
superintendent  of  the  hospital. 

Date  of  visit:  November,  1909. 

TOPEKA:  Population,  45,143. 

(3)  KANSAS  MEDICAL  COLLEGE.  Established  1890.  Since  1902  the  medical  depart- 
ment of  Washburn  College,  which  teaches  chemistry  to  the  medical  students,  but 
is  without  control  of  appointments  in  the  medical  faculty. 

Entrance  requirement:  A  four-year  high  school  course  or  its  equivalent. 
Attendance:  65,  92  per  cent  from  Kansas. 

Teaching  staff:  47,  31  being  professors.  There  are  no  instructors  giving  their  whole 
time  to  the  school,  except  in  so  far  as  chemistry,  above  mentioned,  is  concerned. 

Resources  available  for  maintenance:  Practically  only  fe"es,  amounting  to  $4876  a  year. 

Laboratory  facilities:  The  school  occupies  a  three-story  building,  on  the  upper  floors 
of  which  there  have  been  improvised  laboratories  for  pathology  and  bacteriology. 
They  contain  the  necessary  equipment  for  routine  teaching,  but  are  poorly  kept. 
There  is  a  small  amount  of  apparatus  for  physiological  demonstrations.  The  dis- 
secting-room is  indescribably  filthy ;  it  contained,  in  addition  to  necessary  tables, 
a  single,  badly  hacked  cadaver,  and  was  simultaneously  used  as  a  chicken  yard.1 
There  is  no  museum,  only  a  few  old  books,  some  charts,  a  few  models,  etc. 

1  This  is  explained  as  follows  :  "  It  had  not  been  in  use  for  eight  months  or  so  and  would  not  be  in  use 


228  MEDICAL  EDUCATION 

Clinical  facilities:  A  total  of  eleven  hours  a  week  of  clinical  instruction,  only  nine  of 
which  can  be  attended  by  any  one  student,  is  offered  at  four  different  hospitals. 
The  opportunities,  limited  as  they  are,  are  largely  surgical.  The  feeling  towards 
the  school  is  unusually  cordial,  but  the  hospitals  lack  the  necessary  equipment 
and  organization  for  effective  teaching. 

At  the  time  the  school  was  visited  a  small  room  was  used  for  a  dispensary;  the 
attendance  was  slight;  there  was  no  equipment  at  all.  Recently  larger  quarters 
have  been  provided. 

Date  of  vitit :  November,  1909. 

General  Considerations 

RECENT  action  making  a  year  of  college  work  the  minimum  preliminary  to  prac- 
tise in  Kansas  will  wipe  out  the  eclectic  school  at  Kansas  City  and  the  Topeka 
school,  both  of  which  would,  however,  die  out  even  on  the  present  standard.  The 
future  of  medical  education  in  the  state,  therefore,  very  properly  lies  with  the  state 
university.  This  institution  has  shown  the  desire  to  provide  instruction  of  high  grade 
by  raising  its  entrance  requirements  until  they  now  call  for  two  years  of  college  work; 
but  it  did  not  realize  that  it  was  incumbent  upon  it  to  improve  facilities  and  in- 
struction at  the  same  time.  Great  efforts  must  therefore  be  made  to  hasten  their  de- 
velopment, for  the  higher  entrance  requirement  is  already  in  force.  The  school  is 
now  a  divided  school.  It  would  be  a  simple  matter  to  develop  the  laboratory  end  at 
Lawrence;  it  will  be  difficult  and  expensive  to  develop  the  clinical  end  at  Rosedale 
correspondingly ;  and  still  more  difficult,  to  establish  effective  cooperation  between 
the  severed  halves  of  the  department.  The  needs  of  a  university  medical  department 
are  so  great  that  the  university  will  find  it  necessary  to  refrain  from  many  other 
projects,  pending  the  upbuilding  of  a  creditable  school  of  medicine.  It  is  therefore 
unfortunate  that  the  educational  funds  of  the  state  have  been  already  to  some  extent 
needlessly  consumed  in  the  duplication  of  engineering  and  normal  departments 
within  the  several  state  institutions.  No  comprehensive  and  well  coordinated  scheme 
of  state  educational  development  has  been  worked  out.  It  would  seem  essential  in 
the  first  place  to  demarcate  the  respective  provinces  of  the  several  state  institutions, 
so  that  each  would  care  for  certain  interests  without  trespassing  on  the  ground  re- 
served to  the  others.  That  done,  medicine  would  fall  to  the  state  university  and  would 
include  a  public  health  laboratory.  Certain  fundamental  questions  respecting  the  lo- 
cation, organization,  and  general  scope  of  the  entire  department  would  next  require 
to  be  settled.  Thereafter,  the  plan  adopted  could  be  realized  unit  by  unit,  year  by  year. 


until  cold  weather.  [It  was  then  the  middle  of  November.  1  The  cadaver  happened  to  be  there  be- 
cause of  the  private  studies  of  one  of  the  professors,  who  put  it  there  for  his  own  convenience.  In  the 
same  way,  because  the  room  was  not  in  public  use  and  would  not  be  for  some  time,  another  member 
of  the  faculty  stored  there,  for  use  in  embryology,  the  coop  of  live  chickens." 


KENTUCKY  229 

KENTUCKY 

Population,  2,406,859.  Number  of  physicians,  3708.  Ratio,  1  :  649. 
Number  of  medical  schools,  3. 

LOUISVILLE:  Population,  240,160. 

(1)  UNIVERSITY  OF  LOUISVILLE  MEDICAL  DEPARTMENT.  Organized  1837,  it  has  recently 
absorbed  four  other  schools.  Until  lately  the  university  was  limited  to  loosely 
aggregated  schools  of  law  and  medicine ;  latterly  an  academic  department  without 
endowment  has  been  started. 

Entrance  requirement :  Less  than  a  high  school  education.  Examples  were  found  of 
students  admitted  from  two-year  high  schools  or  less. 

Attendance :  600. 

Teaching"  staff:  90,  of  whom  40  are  professors.  The  distribution  of  the  chairs  is  sig- 
nificant :  the  major  medical  staff  contains  twelve  names,  six  of  them  professors ;  sur- 
gery, twelve  names,  all  professors.  The  laboratory  branches  are  in  marked  contrast : 
two  names  make  the  major  staff  in  physiology,  one  in  chemistry,  one  in  pathology 
and  bacteriology.  There  are  four  whole-time  professors  of  modern  training  in  the 
scientific  departments.  Assistants,  some  of  them  also  giving  entire  time  to  the 
school,  are  provided. 

Resources  available  for  maintenance :  Fees,  amounting  to  $75,125. 

Laboratory  facilities :  Teaching  laboratories  are  provided  for  chemistry,  pathology, 
bacteriology,  physiology,  and  pharmacy.  They  are  inadequate  in  appointments  and 
teaching  force  for  the  thorough  teaching  of  the  fundamental  sciences  to  so  large 
a  student  body.  A  separate  building  has  just  been  set  apart  for  anatomy,  opera- 
tive surgery,  and  the  city  morgue. 

Clinical  facilities :  The  school  has  a  hospital  of  50  beds,  with  an  average  of  30  pa- 
tients, two-thirds  of  the  cases  being  surgical,  and  not  all  available  for  teaching. 
Obstetrical  cases  are  rare,  but  there  is  an  out-patient  obstetrical  service.  At  the 
City  Hospital  eight  amphitheater  clinics  are  held  weekly  for  classes  containing 
from  100  to  300  students.  There  are  no  regular  ward  classes.  The  obstetrical  ward 
is  not  open  to  students ;  there  is  no  pavilion  for  contagious  diseases.  The  hospital 
facilities  are  therefore  poor  in  respect  to  both  quality  and  extent :  unequal  to  the 
fair  teaching  of  an  even  smaller  body  of  students,  they  are  made  to  suffice  for  the 
largest  school  in  the  country. 

The  school  dispensary  has  an  average  daily  attendance  of  over  one  hundred. 
It  is  regularly  used  for  teaching  on  the  section  method. 

Date  of  visit :  December,  1909. 


230  MEDICAL  EDUCATION 

(2)  SOUTHWESTERN  HOMEOPATHIC  MEDICAL  COLLEGE.  Organized  1892.  An  independent 
school. 

Entrance  requirement:  The  same  as  that  of  the  University  of  Louisville  Medical 
Department. 

Attendance:  13. 

Teaching  staff:  27,  12  being  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $1100. 

Laboratory  facilities :  There  is  no  outfit  worth  speaking  of  in  any  department ;  the 
building  is  wretchedly  dirty,  especially  the  room  said  to  be  used  for  anatomy. 
There  is  nothing  to  indicate  recent  dissecting. 

Clinical  facilities :  The  school  gets  one-fifth  of  the  patients  admitted  to  the  City 
Hospital  and  can  use  them  for  demonstrative  purposes. 

There  is  no  organized  dispensary. 
Date  of  visit :  January,  1909. 

(3)  LOUISVILLE  NATIONAL  MEDICAL  COLLEGE  (Colored).  An  independent  school,  organ- 
ized 1888,  now  affiliated  with  the  colored  State  University. 

Entrance  requirement:  Less  than  high  school  education. 

Attendance :  40. 

Teaching"  staff":  23,  of  whom  17  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $2560. 

Laboratory  facilities :  Nominal. 

Clinical  facilities:  A  small  and  scrupulously  clean  hospital  of  8  beds  is  connected  with 

the  school. 
Datt  of  vifit :  January,  1909. 

General  Considerations 

THE  situation  in  Kentucky  is  a  simple  one.  The  homeopathic  school  is  without  merit. 
Its  graduates  deserve  no  recognition  whatsoever,  for  it  lacks  the  most  elementary 
teaching  facilities.  The  University  of  Louisville  has  a  large,  scattered  plant,  unequal 
to  the  strain  which  numbers  put  upon  it.  In  the  old  days,  Louisville,  with  a  half- 
dozen  "  regular ""  schools,  was  a  popular  medical  center,  to  which  crude  boys  thronged 
from  the  plantations.  The  schools  offered  little  beyond  didactic  teaching.  Now,  they 
have  been  arithmetically  added  together;  the  resulting  school  is  indeed  superior  on 
the  laboratory  side  to  any  of  its  component  parts ;  but  there  are  radical  defects  for 
which  there  is  no  cure  in  sight.  The  classes  are  unmanageably  huge ;  the  laboratories 
overcrowded  and  undermanned;  clinical  facilities,  meager  at  best,  broken  into  bits 
in  order  to  be  distributed  among  the  aggregated  faculty.  To  carry  the  school  at  all, 


LOUISIANA  231 

a  large  attendance  is  necessary ;  but  a  large  attendance  implies  a  low  standard.  The 
situation  is  thus  practically  deadlocked. 

The  outlook  is  not  promising;  for  there  is  no  indication  of  such  support,  financial 
or  academic,  as  would  be  required  in  order  to  reconstruct  the  institution  on  accept- 
able lines.  Elsewhere  a  strong  college  or  university  has  been  in  reach :  as,  for  example, 
across  the  Ohio,  Indiana  University  has  just  now  put  its  hand  to  the  plow  and 
will  not  turn  back.  But  in  Kentucky  the  state  university  is  totally  unequal  to  the 
task.  It  labors  under  the  initial  disadvantage  of  being  situated  in  another  town, — 
not  the  less  a  disadvantage  because  capable  of  being  overcome;  more  serious,  how- 
ever, is  its  educational  ineptitude.  It  has  never  been  an  active  educational  factor, 
and  having  now  chosen  a  politician,  without  educational  qualification  or  experience, 
as  its  president,  its  immediate  future  promises  little.  From  the  existing  so-called  aca- 
demic department  of  the  University  of  Louisville  neither  aid  nor  ideals  can  come. 
It  is  quite  without  resources.  We  have  indeed  progressed  too  far  in  our  social  and 
educational  development  to  use  the  word  "university  ""for  an  enterprise  of  this  kind. 
Classes  in  literature,  languages,  and  elementary  science  may  indeed  be  organized  by 
volunteer  teachers,  in  hours  left  open  by  their  regular  engagements,  or  by  instruc- 
tors supported  from  year  to  year  by  subscription ;  they  may  discharge  a  highly  use- 
ful office  in  any  community,  but  they  ought  to  be  called  by  their  right  name.  An 
academic  department  of  a  university  they  are  not :  why  should  they  not  be  described  as 
a  people's  institute,  or  by  some  other  designation  calculated  to  indicate  their  actual 
character?1  The  loose  use  of  the  words  "college*1  and  "university"  prolongs  educa- 
tional chaos;  it  hinders  the  apprehension  of  genuine  and  fundamental  educational 
distinctions.  Assuredly,  an  institute  of  the  type  described  cannot  dominate  or  trans- 
form a  hitherto  independent  group  of  medical  schools. 


LOUISIANA 

Population,  1,618,358.  Number  of  physicians,  1798.  Ratio,  1 :  900. 
Number  of  medical  schools,  2. 

NEW  ORLEANS:  Population,  332,169. 

(1)  MEDICAL  DEPARTMENT  OF  THE  TULANE  UNIVERSITY  OF  LOUISIANA.  Organized  in 
1834,  the  school  affiliated  with  the  University  of  Louisiana  in  1845,  and  with  Tulane 
in  1884,  at  which  date  the  University  of  Louisiana  became  Tulane  University.  In 
1902  it  assumed  its  present  status  as  an  organic  part  of  the  university. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent,  admin- 
istered by  the  academic  authorities.  The  actual  standard  is  somewhat  below  the 
nominal  standard,  though  gradually  rising  towards  it. 

1  These  comments  apply  with  equal  force  to  Toledo. 


«S«  MEDICAL  EDUCATION 

Attendance:  439. 

Teaching  staff:  75,  of  whom  17  are  professors.  The  laboratory  branches  are  in  charge 
of  five  men,  who  give  their  entire  time  to  teaching  and  investigation. 

Resources  available  for  maintenance:  Endowment  funds,  aggregating  about  $900,000, 
yield  an  income  of  $26,000  annually ;  fees  amount  to  $67,500.  The  budget  of  the 
department  amounts  to  $101,781. 

Laboratory  facilities:  New  and  excellent  laboratories  are  provided  for  the  work  of 
the  first  and  second  years.  The  professors  in  charge  represent  modern  ideals,  and 
are  enthusiastically  engaged  in  reconstructing  the  entire  school  on  progressive 
lines.  The  anatomical  museum  is  one  of  the  best  in  the  country.  The  library  is  small. 

Clinical  facilities:  The  school  enjoys  unusual  privileges  and  opportunities  in  the 
Charity  Hospital,  an  institution  of  1050  beds.  Recently  an  additional  ward  for 
surgery  and  gynecology  has  been  added,  full  control  of  the  services  being  vested 
in  the  Tulane  faculty  by  the  terms  of  the  gift.  The  abundant  material  is  freely 
used  by  the  medical  faculty,  though  certain  defects  of  organization,  equipment, 
and  relationship  must  be  corrected  in  order  to  render  the  situation  ideal.  The 
main  point,  however,  is  secure,  for  the  position  of  the  medical  school  in  the  hos- 
pital is  ensured  through  legislative  enactment.  The  professorship  in  medicine  has 
recently  been  filled  by  importation  without  any  friction  whatsoever. 
The  dispensary  service  is  adequate. 

Postgraduate  instruction  in  specialties  is  offered  by  the  New  Orleans  Polyclinic, 
affiliated  with  the  Tulane  University. 

(2)  FLINT  MEDICAL  COLLEGE  (Colored).  Organized  in  1889,  it  is  a  department  of  New 
Orleans  University,  which  is  managed  by  the  Freedman's  Aid  Society  of  the 
Methodist  Episcopal  Church,  North. 

Attendance:  24. 

Teaching  staff:  15,  of  whom  6  are  professors.  All  are  practitioners. 

Resources  available  for  maintenance:  Tuition  fees,  $1300  (estimated),  and  small  ap- 
propriations voted  by  the  Freedman's  Aid  Society  constitute  the  income.  The  entire 
budget,  including  that  of  the  hospital  adjoining,  is  less  than  $10,000  annually. 

Laboratory  facilities :  There  is  scant  equipment  in  anatomy,  chemistry,  pathology, 
and  bacteriology.  The  rooms  are  in  poor  condition. 

Clinical  facilities:  The  school  controls  a  hospital  of  20  beds,  with  an  average  of  17 
patients  monthly,  and  a  dispensary  with  an  average  daily  attendance  of  one  or  two. 
Date  ofvitit:  January,  1909. 


MAINE  233 

General  Considerations 

THE  medical  department  of  Tulane  University  is  one  of  a  very  few  existing  southern 
schools  that  deserve  development.  The  south  is  in  general  overcrowded  with  schools 
with  which  nothing  can  be  done;  for  they  are  conducted  by  old-time  practitioners, 
who  could  not  use  improved  teaching  facilities  if  they  were  provided.  The  case  is 
different  at  Tulane.  Its  recent  reorganization  has  put  imported  men  of  modern  train- 
ing and  ideals  in  charge  of  the  most  important  departments,  laboratory  and  clinical. 
There  is  no  question  that  if  properly  supported,  they  will  quickly  bring  the  institu- 
tion to  a  position  of  commanding  influence.  To  achieve  this  result,  the  school  must 
be  freed  of  the  necessity  of  so  largely  relying  upon  fees  for  its  support.  For  once 
rendered  by  endowment  comparatively  independent,  it  can  use  its  superior  opportu- 
nities as  a  lever  to  brace  up  the  general  educational  situation  of  the  southern  states. 
It  could  compel  those  seeking  these  opportunities  to  improve  their  preparation  at 
least  to  the  full  limit  of  local  possibilities.  The  urgent  need  of  the  south  is  an  object 
lesson  in  medical  education,  such  as  will  prominently  embody  what  is  sound  and  de- 
sirable; and  such  an  object  lesson  the  medical  department  of  Tulane  could  readily 
be  made:  it  possesses  already  the  laboratories  and  the  hospital;  it  requires  only  the 
means  that  will  enable  it  to  utilize  them  fully. 

Flint  Medical  College  is  a  hopeless  affair,  on  which  money  and  energy  alike  are 
wasted.  The  urgent  need  in  respect  to  the  medical  education  of  the  negro  is  con- 
centration of  resources  slender  at  best  on  a  single  southern  institution.  Much  the 
most  favorably  situated  for  this  purpose  is  Meharry  Medical  College  at  Nashville. 

MAINE 

Population,  724,508.  Number  of  physicians,  1198.  Ratio,  1 :  600. 
Number  of  medical  schools,  1. 

BRUNSWICK-PORTLAND:  (Population:1  Brunswick,  2321;  Portland,  58,512). 

MEDICAL  SCHOOL  OF  MAINE.  Organized  1820.  A  divided  school,  being  the  medical 
department  of  Bowdoin  College. 

Entrance  requirement:  Four-year  high  school  diploma  or  equivalent,  ascertained  by 
examination,  conducted,  however,  under  the  auspices  of  the  medical  school,  not 
by  Bowdoin  College,  and  below  the  college  standard.  Certificates  are  accepted  far 
below  standard  in  value. 

Attendance:  81,  86  per  cent  from  Maine. 

Teaching  staff:  35,  14  being  professors,  21  of  other  grade. 

1  Census  Bureau  without  data. 


234  MEDICAL  EDUCATION 

Resources  available  for  maintenance:  From  endowment,  $7600;  from  fees,  $8100; 
total,  $15,700. 

Laboratory  facilities  :The  laboratory  branches  are  taught  in  the  medical  school  building 
at  Brunswick  with  the  exception  of  chemistry,  which  is  well  provided  for  in  the  col- 
lege laboratories ;  the  equipment  covering  physiology,  bacteriology,  and  pathology 
is  slender.  There  is  nothing  in  pharmacology  at  all.  There  are  no  whole-time  teachers 
in  the  scientific  branches.  The  professor  of  anatomy  is  non-resident;  his  main  duty 
is  lecturing,  the  dissecting-room  being  supervised  by  recent  graduates,  engaged  in 
practice.  "The  professor  looks  in  occasionally."  The  professor  of  pathology  is  phy- 
sical director  of  Bowdoin  College.  The  professor  of  physiology  is  non-resident. 

Clinical  facilities:  Clinical  instruction  is  given  at  Portland  by  teachers  who  have  little 
commerce  with  the  laboratories  at  Brunswick.  The  chief  clinical  reliance  of  the 
school  is  the  Maine  General  Hospital,  where  instruction  is  given  principally  in 
the  amphitheater,  as  a  majority  of  the  cases  are  surgical.  Obstetrical  work  is  not 
to  be  counted  on.  Internes  do  the  clinical  laboratory  work  and  make  up  case  his- 
tories. The  records  are  indexed  only  by  name  of  the  patient.  Additional  clinical 
material  is  obtained  at  the  Eye  and  Ear  Infirmary,  Children's  Hospital,  etc. 

Students  spend  also  a  small  amount  of  time  at  a  thoroughly  wretched  city  dis- 
pensary, where  the  cases  are  few,  where  no  records  are  kept,  and  where  not  even 
copies  of  prescriptions  are  filed.  The  dispensary  does  not  own  a  microscope. 

A  course  in  clinical  microscopy  is  given  at  the  college  building  in  Portland. 
"Urine  and  sputum  are  gathered,  and  students  are  told  about  the  cases  from 
which  they  come."  Neither  end  of  this  school  meets  the  requirements  for  the  teach- 
ing of  modern  medicine. 

Date  of  visit:  October,  1909. 

[For  general  discussion  see  "  New  England,"  p.  261.] 

MARYLAND 

Population,  1,319,132.  Number  of  physicians,  2012.  Ratio,  1 :  658. 
Number  of  medical  schools,  7. 

BALTIMORE:  Population,  583,475. 

(1)  MEDICAL  DEPARTMENT  OF  THE  JOHNS  HOPKINS  UNIVERSITY.  Established  1893.  An 
organic  university  department. 

Entrance  requirement:  The  bachelors  degree,  representing  specific  attainments  in 
chemistry,  physics,  biology,  German,  and  French. 

Attendance:  297. 

Teaching  staff:  112,  of  whom  23  are  professors.  All  the  laboratory  teaching  is  con- 
ducted by  instructors  who  give  their  entire  time  to  teaching  and  research ;  the  heads 


MARYLAND  235 

of  the  clinical  departments  are  salaried  teachers  attached  to  the  Johns  Hopkins 
Hospital. 

Resources  available  for  maintenance:  The  income  from  tuition  fees  is  $60,542,  that 
from  endowments  $19,687,making  a  total  of $80,229.  The  budget  calls  for$102,429, 
not  including  salaries  of  the  clinical  faculty  and  other  items  carried  by  the  Johns 
Hopkins  Hospital,  which  is  thus  actually  an  integral  part  of  the  medical  school. 
The  productive  hospital  endowments  now  aggregate  $3,632,289,  not  including  the 
bequests  for  the  Phipps  Psychiatric  Clinic  and  the  Harriet  Lane  Johnson  Home 
for  Children. 

Laboratory  facilities:  These  facilities  are  in  every  respect  unexcelled.  As  the  institu- 
tion has  been  from  the  beginning  on  a  graduate  basis,  teaching  and  research  have 
been  always  equally  prominent  in  its  activities. 

Clinical  facilities:  The  Johns  Hopkins  Hospital  and  Dispensary  provide  practically 
ideal  opportunities.  The  medical  staff  of  the  hospital  and  the  clinical  faculty  of 
the  medical  school  are  identical;  the  scientific  laboratories  ranged  around  the  hos- 
pital are  in  close  touch  with  clinical  problems,  immediate  and  investigative.  The 
medical  school  plant  is  thus  an  organic  whole,  in  which  laboratories  and  clinics 
are  inextricably  interwoven.  Recent  foundations  have  greatly  augmented  the  ori- 
ginal hospital  plant  in  the  direction  of  psychiatry,  pediatrics,  and  tuberculosis. 
Three  hundred  and  eighty-five  beds  under  complete  control  are  now  available. 

The  dispensary  is  largely  attended,  and  is  admirably  conducted  from  the  stand- 
point of  both  public  service  and  pedagogic  efficiency. 

Date  ofvitit:  December,  1909, 

(2)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Established  1872.  An  independent  insti- 
tution. 

Entrance  requirement:  Less  than  a  high  school  education. 
Attendance:  252. 

Teaching  staff":  59,  of  whom  21  are  professors,  38  of  other  grade.  One  teacher  devotes 
his  entire  time  to  medical  instruction. 

Resources  available  for  maintenance:  Fees,  amounting  to  $39,000. 

Laboratory  facilities :  Ordinary  working  laboratories  are  provided  for  bacteriology, 
histology,  and  pathology,  including  surgical  pathology ;  the  chemical  laboratory 
provides  satisfactorily  for  general  chemistry.  The  dissecting-room  is  fair,  as  far  as 
it  goes.  There  is  no  experimental  pharmacology  and  no  student  work  in  experi- 
mental physiology.  The  museum  consists  of  several  hundred  specimens;  the  library, 
of  which  there  is  a  librarian  in  charge,  of  perhaps  1500  volumes  and  a  few  current 
periodicals.  The  undeveloped  character  of  the  laboratories  is  due,  (1)  to  the  pay- 


286  MEDICAL  EDUCATION 

ment  of  faculty  dividends;  (2)  to  the  application  of  current  fee  income  to  the  dis- 
charge of  building  debts. 

Clinical  facilities:  The  school  completely  controls  the  adjoining  hospital,  of  which 
some  210  beds,  including  a  maternity  ward,  are  available  for  teaching.  Ward- 
teaching  on  the  section  plan  is  in  use.  The  clinical  laboratory  is  open  to  the 
students. 

The  dispensary  occupies  an  excellent  suite  of  rooms ;  the  attendance  is  ample. 

Dat«  ofvint:  March,  1909. 

(8)  UNIVERSITY  or  MARYLAND  SCHOOL  OF  MEDICINE.  Organized  1807.  Essentially  an 
independent  institution  with  a  university  charter,  though  nominally  the  medical 
department  of  St.  John's  College  (Annapolis) . 

Entrance  requirement:  Less  than  a  high  school  education. 

Attendance:  316. 

Teaching  staff':  61,  of  whom  24  are  professors,  37  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $44,530  (estimated),  out  of 
which  dividends  are  paid  to  the  faculty  and  a  large  mortgage  debt  carried. 

Laboratory  facilities :  Good  undergraduate  laboratories  adequate  to  routine  teaching 
are  provided  in  two  poorly  kept  buildings  for  the  following  subjects:  chemistry, 
physiology,  including  physiological  chemistry  and  histology,  pathology  and  bac- 
teriology. Anatomy  is  poor.  There  is  a  small  museum.  In  a  separate  building  is  a 
large  and  interesting  library,  but  it  is  open  only  two  hours  each  day. 

Clinical  facilities:  The  school  controls  its  own  hospital,  opposite  the  laboratory  build- 
ings, about  140  beds  being  available  for  teaching.  The  hospital  records  are  well 
kept,  senior  students  who  pay  for  the  privilege  serving  as  clinical  assistants.  A 
separate  maternity  ward  furnishes  obstetrical  work  in  abundance. 
The  dispensary  is  large,  properly  equipped,  and  well  kept. 

Date  of  vitit :  March,  1909. 

(4)  BALTIMORE  MEDICAL  COLLEGE.  Organized  1881.  An  independent  institution. 

Entrance  requirement:  Much  less  than  a  four-year  high  school  education.  Advanced 
standing  is  freely  granted  to  failed  students  dropped  from  other  schools. 

Attendance:  392. 

Teaching  staff:  63,  of  whom  20  are  professors,  43  of  other  grade.  There  are  no 
teachers  giving  entire  time  to  medical  instruction. 

Resources  available  for  maintenance:  Fees,  amounting  to  833,424. 

Laboratory  facilities :  The  school  possesses  a  new  and  very  attractive  laboratory 


MARYLAND  237 

building.  It  is  well  equipped  for  undergraduate  instruction  in  chemistry  and 
pathology;  inadequately  for  physiology  and  bacteriology.  A  large  room  with 
ample  material  provides  for  dissecting. 

Clinical  facilities:  The  school  has  the  use  of  about  122  beds  in  a  hospital  which  it 
built  and  has  leased  to  the  Sisters  of  Charity ;  it  has  access  to  several  other  institu- 
tions besides. 

A  suite  of  poorly  kept  rooms  is  set  aside  for  a  dispensary.  The  attendance  is  ample. 

Date  of  visit:  March,  1909. 

(5)  WOMAN'S  MEDICAL  COLLEGE  OF  BALTIMORE.  Organized  1882.  An  independent 
institution. 

Entrance  requirement:  Less  than  a  high  school  education. 
Attendance:  22. 

Teaching  staff':  31,  of  whom  18  are  professors,  13  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  $2000. 

Laboratory  facilities:  Small  laboratories,  scrupulously  well  kept,  show  a  desire  to 
do  the  best  possible  with  meager  resources :  pathology,  bacteriology,  embryology, 
chemistry,  and  anatomy  are  thus  taught. 

Clinical  facilities:  These  are  quite  insufficient:  across  the  street  from  the  school  is  a 
hospital  with  17  beds;  supplementary  material  is  obtained  at  several  institutions 
through  staff  connections. 

A  suite  of  rooms  in  the  college  building  is  devoted  to  dispensary  purposes. 
There  is  a  fair  attendance. 

Date  of  visit :  March,  1909. 

(6)  MARYLAND  MEDICAL  COLLEGE.  Organized  1898.  An  independent  institution. 
Entrance  requirement:  Nominal. 

Attendance:  95.  Almost  one-half  the  school  is  in  the  senior  class. 
Teaching  staff:  39,  of  whom  21  are  professors,  18  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  $7460  (estimated). 

Laboratory  facilities :  The  school  building  is  wretchedly  dirty.  Its  so-called  labora- 
tories are  of  the  worst  existing  type :  one  neglected  and  filthy  room  is  set  aside 
for  bacteriology,  pathology,  and  histology:  a  few  dirty  test-tubes  stand  around 
in  pans  and  old  cigar-boxes.  The  chemical  laboratory  is  perhaps  equal  to  the 
teaching  of  elementary  chemistry.  The  dissecting-room  is  foul.  This  description 
completely  exhausts  its  teaching  facilities.  There  is  no  museum  or  library  and 
no  teaching  accessories  of  any  sort  whatsoever. 


2  38  MEDICAL  EDUCATION 

Clinical  facilities:  The  college  faculty  own  and  conduct  a  hospital  within  a  few  blocks. 
It  is  essentially  a  private  institution,  of  no  great  value  to  students.  Less  than  50 
beds  are  free. 

The  dispensary  claims  a  fair  attendance. 

Dot*  of  visit:  March,  1909. 

(7)  ATLANTIC  MEDICAL  COLLEGE.  Organized  1891  as  an  independent  homeopathic 
institution.  Having  "passed  through  many  vicissitudes,"  it  is  now  non-sectarian. 

Entrance  requirement:  Nominal. 

Attendance:  43,  of  whom  31  are  in  the  senior  class,  1  in  the  freshman  class.  Of  21 
graduates,  class  of  1908,  almost  all  had  failed  at  other  schools  or  before  the  regu- 
lar state  board  before  entering  the  Atlantic  Medical  College,  on  graduation  from 
which  they  could  appear  before  the  Homeopathic  State  Board  of  Maryland,  "re- 
puted to  be  a  much  easier  board  to  pass." 

Teaching  staff":  47,  of  whom  12  are  professors,  35  of  other  grade.  Two  members  of 
the  teaching  staff  were  graduated  in  the  class  of  1908,  above  mentioned,  after 
having  failed  before  the  regular  state  board;  a  third  instructor,  also  a  graduate 
of  1908,  entered  this  school  after  failure  at  the  local  College  of  Physicians  and 
Surgeons. 

Resources  available  for  maintenance:  Fees,  amounting  to  $3905  (estimated). 

Laboratory  facilities:  The  school  occupies  a  filthy  building,  in  which  are  to  be  found 
an  elementary  chemical  laboratory,  a  small  room  assigned  to  pathology,  bacte- 
riology, and  histology,  equipment  being  scant  and  dirty,  an  ordinary  dissecting- 
room,  a  lecture-room  with  half  a  skeleton,  a  small  amount  of  imperfect  physiolo- 
gical apparatus  with  a  few  frogs,  and  a  few  cases  of  books,  mostly  old  and  use- 
less. 

Clinical  facilities:  These  are  claimed  at  a  small  private  hospital  several  miles  off. 
They  can  at  best  be  hardly  more  than  nominal. 

The  basement  of  the  college  building  is  used  for  a  dispensary. 
DaU  ofvitit:  March,  1909. 

General  Considerations 

THERE  are  seven  medical  schools  in  Maryland,  a  state  whose  population  increases 
slowly  and  in  which  there  are  between  two  and  three  times  as  many  physicians  as  it 
now  requires.  Of  these  seven  schools,  two  belong  to  the  worst  type  of  American 
medical  school,  viz.,  the  Atlantic  Medical  College  and  the  Maryland  Medical  College. 
That  such  unconscionable  concerns  should  at  this  day  continue  to  flourish  is  a  blot 
upon  the  state  of  Maryland  and  the  city  of  Baltimore. 

Two  more  of  the  seven  schools,  the  Baltimore  Medical  College  and  the  Woman's 


MASSACHUSETTS  239 

Medical  College,  are  weak ;  two  others,  the  College  of  Physicians  and  Surgeons  and 
the  University  of  Maryland,  are  large  commercial  enterprises,  whose  financial  respon- 
sibilities are  far  too  extensive  for  their  capital  or  fee  income;  the  sums  annually  ap- 
plicable to  debts  in  order  to  simplify  their  position,  or  to  maintenance  in  order  to 
improve  their  teaching,  are  reduced  by  the  payment  of  substantial  dividends  to 
practitioner  teachers.  Education  is  thus  overshadowed  by  business.  Entrance  stand- 
ards are  low,  the  full-time  teacher  is  practically  unknown,  the  laboratories  are  slov- 
enly, the  atmosphere  depressing. 

Like  Pennsylvania,  Maryland  has  granted  lump  sums  to  private  corporations  en- 
gaged in  charitable  work.  The  larger  ones  of  the  six  medical  schools  mentioned  have 
thus  combined  to  obtain  from  the  state  money  enough  to  build  and  partly  to  sup- 
port their  hospitals.  Should  the  state  ever  conduct  its  philanthropic  business  intel- 
ligently, these  irresponsible  methods  would  stop;  and  with  them,  the  medical  schools 
which  they  have  helped  to  float.  The  Johns  Hopkins  Medical  School,  for  which 
neither  the  state  of  Maryland  nor  the'  city  of  Baltimore  has  ever  done  anything,  is 
thus  the  only  medical  school  in  Maryland  that  either  ought  to  or  can  live,  and  to  its 
development  greatly  increased  means  should  be  freely  devoted. 

If,  meanwhile,  a  combination  of  the  better  independent  schools  of  Baltimore  were 
effected,  much  of  their  property  could  be  disposed  of,  the  equity  being  used  to  equip 
the  resulting  institution.  A  single  independent  school  might  thus  have  a  brief  and 
not  discreditable  career.  In  the  end,  however,  the  independent  schools  will  pass  away, 
in  Maryland  as  elsewhere.  To  their  present  hospitals  the  Johns  Hopkins  would  be- 
come the  heir,  thus  greatly  strengthening  its  clinical  resources.  At  this  date  the 
Johns  Hopkins  University  is  the  only  academic  institution  in  the  state  capable  of 
conducting  a  modern  medical  school.  It  would  be  safe,  interesting,  and  instructive 
to  leave  medical  education  in  Maryland  for  a  decade  or  two  wholly  in  its  hands.  The 
state  will  not  meanwhile  lack  for  doctors;  it  is  already  overcrowded. 

The  prerequisite  to  any  reconstruction  of  the  Baltimore  situation  is  the  revision 
of  the  state  law.  The  country  affords  no  more  conclusive  proof  of  the  viciousness  of 
the  two-board  system.  Not  only  is  neither  state  board  empowered  to  enforce  a  pre- 
liminary educational  requirement,  but  candidates  refused  by  the  "regular"  board 
subsequently  succeed  before  the  homeopathic  board.  This  underground  traffic  is  re- 
sponsible for  the  existence  of  the  Atlantic  Medical  College,  a  homeopathic  school 
that  has  rendered  itself  an  attractive  haven  of  refuge  to  rejected  "regular'"  students 
by  dropping  the  significant  word  from  its  title. 


MASSACHUSETTS 

Population,  3,162,347.  Number  of  physicians,  5,577.  Ratio,  1 :  567. 
Number  of  medical  schools,  5. 


240  MEDICAL  EDUCATION 

BOSTON :  Population,  629,868. 

(1)  MEDICAL  SCHOOL  OF  HARVARD  UNIVERSITY.  Organized  1782.  An  integral  depart- 
ment of  Harvard  University. 

Entrance  requirement :  The  student  has  a  choice  between  the  bachelor's  degree  or  cer- 
tain definite  requirements  in  science  and  modern  languages  representing  two  years 
of  undergraduate  work,  provided  that  in  the  latter  case  a  higher  passing  mark  is 
required  for  graduation.  In  the  present  year,  out  of  a  first-year  class  of  62,  60  en- 
tered with  the  bachelor's  degree. 

Attendance :  The  total  enrolment  is  285 ;  about  69  per  cent  from  New  England,  53 
per  cent  from  Massachusetts. 

Teaching  staff:  173,  of  whom  23  are  professors  ;  laboratory  instructors  as  a  rule  de- 
vote their  entire  time  to  the  department. 

Resources  available  for  maintenance:  The  department  has  an  endowment  of  $3,326,- 
961 ;  the  fees  are  merged  in  the  general  income  of  the  school.  The  annual  budget 
is  $251,389,  of  which  $72,037  are  derived  from  tuition  fees. 

Laboratory  facilities :  The  laboratories  are  unexcelled  in  equipment  and  organiza- 
tion, in  respect  to  both  teaching  and  research. 

Clinical  facilities :  Abundant  clinical  material  is  available  at  the  Massachusetts  Gen- 
eral Hospital,  the  City  Hospital,  and  elsewhere.  But  serious  restrictions  are  felt 
in  two  directions  :  (1)  While  the  university  is  free  to  secure  laboratory  men  wher- 
ever it  chooses,  it  is  practically  bound  to  make  clinical  appointments  by  seniority, 
in  accordance  with  the  custom  prevailing  in  the  hospital  which  it  uses,  or  to  leave 
its  professor  without  a  hospital  clinic.  In  general  it  follows  that  the  heir  to  the 
hospital  service  is  heir  to  the  university  chair.  In  consequence  there  is  a  noticeable 
lack  of  sympathy  between  the  laboratory  and  the  clinical  men.  They  do  not  repre- 
sent the  same  ideals.  There  is  no  question  but  that  an  institution  of  this  rank  ought 
to  work  in  the  most  intimate  cooperation  with  a  hospital ;  and  that,  if  such  were 
the  case,  the  same  principles  would  obtain  in  selecting  clinical  teachers  as  prevail 
elsewhere  in  the  university.  (2)  The  extent  to  which  hospital  material  can  be  util- 
ized is  also  limited,  though  less  in  surgery  than  in  medicine.  The  teaching  is  in 
the  main  of  the  demonstrative  character.  Something  more  intimate  is  possible  in 
a  limited  way  with  fourth-year  students.  The  hospital  services  with  one  exception 
rotate  at  the  end  of  periods  of  four  months. 

The  school  is  now  installing  its  own  dispensary,  likely  to  be  of  great  value  in 
its  clinical  instruction. 

DaU  of  vifit :  October,  1909. 

(2)  TOFTS  COLLEGE  MEDICAL  SCHOOL.  Organized  1893.  Administratively  an  integral 
department  of  Tufts  College,  though  actual  scientific  intercourse  is  not  intimate. 


MASSACHUSETTS  241 

Entrance  requirement:  Below  an  actual  four-year  high  school  course,  since  certificates 
of  uncertain  value  have  been  accepted  and  examinations  used  cover  less  than  half 
a  high  school  course.  This  is  the  less  defensible  as  97  percent  of  the  total  enrol- 
ment come  from  New  England. 

Attendance:  The  attendance  is  384;  97  per  cent  from  New  England,  80  per  cent  from 
Massachusetts. 

Teaching  staff:  103,  of  whom  33  are  professors.  There  are  five  full-time  professors 
and  five  full-time  assistants  in  pathology,  histology,  physiology,  and  chemistry. 

Resources  available  for  maintenance:  The  school  relies  on  its  fees,  amounting  to 
$59,093,  repaying  out  of  them  large  advances  for  buildings  made  out  of  the  general 
income  of  the  college. 

Laboratory  facilities:  The  laboratories  are  entirely  adequate  to  the  teaching  work  of 
the  school. 

Clinical  facilities:  For  medical  clinics  the  school  is  confined  to  the  Boston  City  Hos- 
pital and  the  Boston  Dispensary,  which  furnish  abundant  material  under  the  usual 
more  or  less  imperfect  control.  The  Carney  Hospital  provides  considerable  addi- 
tional work  in  surgery;  the  specialties  are  cared  for  in  other  institutions.  The 
school  is  thus  clinically  handicapped  in  exactly  the  same  way  as  Harvard,  but 
to  a  greater  degree  by  reason  of  its  being  restricted  in  its  medical  clinics  to  a 
single  municipal  hospital  and  dispensary.  Its  range  of  choice  in  the  matter  of 
clinical  professors  is  limited  by  the  same  considerations. 

Date  of  visit:  October,  1909. 

(3)  BOSTON  UNIVERSITY  SCHOOL  OF  MEDICINE.  Homeopathic.  Organized  1873.  The 
University  connection  is  nominal. 

Entrance  requirement:  A  certificate  of  graduation  from  an  approved  four-year  high 
school,  or  examination ;  the  examination  is  not  set  by  the  university,  but  by  the 
medical  school,  and  is  markedly  below  the  four-year  high  school  standard. 

Attendance:  Total  enrolment,  90;  83  per  cent  from  New  England,  about  60  per  cent 
from  Massachusetts. 

Teaching  staff:  64,  29  being  professors. 

Resources  available  for  maintenance:  The  institution  is  mainly  dependent  on  fees 
($12,762,  estimated),  but  these  have  been  consistently  used  to  develop  its  facilities. 

Laboratory  facilities :  In  striking  contrast  with  schools  in  which,  whatever  the  claim, 
fees  have  not  been  so  used,  this  school  has  an  excellent  building,  admirably  kept 
and  well  equipped,  and  attractive  laboratories  for  pathology,  bacteriology,  physi- 
ology, chemistry,  and  anatomy.  There  is  no  experimental  pharmacology.  It  pos- 
sesses a  library  in  charge  of  a  permanent  librarian,  a  beautifully  mounted  collection 


MEDICAL  EDUCATION 

of  pathological  material,  an  excellent  refrigerator  plant,  and  other  features  in- 
dicative of  intelligent  and  conscientious  effort. 

Clinked  facilities:  The  school  adjoins  a  hospital  of  some  230  beds,  of  which  125  are 
available  for  amphitheater  and  ward  clinics.  The  material  is  fairly  abundant  and 
varied;  but  students  do  not  make  laboratory  examinations  for  the  patients  whom 
they  see  in  the  wards.  A  pavilion  for  contagious  diseases  is  also  accessible.  Con- 
nected with  the  hospital  is  a  large,  thoroughly  modern,  and  systematically  con- 
ducted dispensary,  in  which  laboratory  work  and  physical  examination  are  more 
closely  connected. 

Dat«  ofvltU:  October,  1909. 

(4)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  1882.  An  independent  insti- 
tution. 

Entrance  requirement :  Vague. 

Attendance:  172,  called  in  the  catalogue  "matriculates  and  applicants." 

Teaching  staff:  30  professors  and  15  lecturers. 

Resources  available  for  maintenance :  Fees,  amounting  to  $10,000  (estimated).  A  re- 
duction of  20  per  cent  is  made  to  students  who  pay  in  advance  for  the  entire  four 
years. 

Laboratory  facilities :  These  facilities  are  wretched  :  ill-lighted,  dirty,  and  poorly 
equipped  so-called  laboratories  are  provided  for  anatomy,  pathology,  etc. 

Clinkal  facilities :  The  clinical  resources  are  dubious.  The  catalogue  attempts  to  con- 
vey the  idea  (p.  21)  that  the  school  has  the  same  opportunities  as  Harvard  and 
Tufts ;  as  a  matter  of  fact,  no  member  of  the  faculty  of  the  College  of  Physicians 
and  Surgeons  has  a  staff  appointment  in  the  City  Hospital,  and  teaching  there  is 
utterly  impossible  otherwise.  The  same  is  true  of  the  wards  of  the  Massachusetts 
General  Hospital.  At  both  institutions  anyone,  whether  a  student  or  not,  may 
attend  the  public  amphitheater  clinics  once  weekly.  But  as  these  are  freely  open 
to  the  public  and  are  of  little  or  no  value,  they  are  hardly  to  be  counted  as  teaching 
facilities.  A  limited  attendance  is  required  at  a  miserable  dispensary,  more  than 
an  hour's  journey  from  the  college  building. 

Dot*  ofvint:  October,  1909. 

CAMBRIDGE :  Population,  102,982. 

(5)  MASSACHUSETTS  COLLEGE  OF  OSTEOPATHY.  Established  1897.  An  independent  in- 
stitution. 

Entrance  requirement :  Vague. 
Attendance:  90. 


MICHIGAN  243 

Teaching  staff:  34,  of  whom  19  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  811,400  (estimated). 

Laboratory  facilities :  The  school  occupies  a  neatly  kept  building,  in  which  are  pro- 
vided one  poorly  equipped  laboratory  in  common  for  pathology  and  bacteriology, 
and  another,  similar  in  character,  for  chemistry  and  urinalysis,  and  an  anatomical 
room.  It  possesses  neither  museum  nor  library.  Instruction  at  the  school  building 
is  limited  to  lectures,  recitations,  and  "  laboratory  "  work. 

Clinical  facilities :  No  "  treatment"  is  administered  in  the  school  building.  For  that 
the  students  resort  in  their  last  year  to  the  Chelsea  Hospital,  a  pay  institution 
of  10  to  15  beds,  more  than  one  hour's  journey  from  the  college  building.  Patho- 
logy is  taught  in  the  same  year. 

Date  of  visit :  October,  1909. 

{For  general  discussion  see  "  New  England"  p.  261.} 

MICHIGAN 

Population,  2,666,308.  Number  of  physicians,  4109.  Ratio,  1 :  649. 
Number  of  medical  colleges,  5. 

ANN  ARBOR:  Population,  14,734. 

(1)  UNIVERSITY  OF  MICHIGAN  DEPARTMENT  OF  MEDICINE  AND  SURGERY.  Organized  in 
1850.  An  integral  part  of  the  university. 

Entrance  requirement:  Two  years  of  college  work,  including  sciences  strictly  enforced. 
Attendance:  389,  45  per  cent  from  Michigan. 

Teaching  staff:  63,  of  whom  22  are  professors.  The  laboratory  work  is  wholly  in 
charge  of  full-time  instructors ;  but  assisi^ints  in  adequate  number  are  lacking.  The 
clinical  teachers  are  salaried  and  owe  their  first  duty  to  the  school. 

Resources  available  for  maintenance:  The  school  and  the  university  hospital  are  sup- 
ported mainly  by  state  appropriation.  The  budget  of  the  school  is  $83,000,  that  of 
the  hospital,  $70,000.  Endowments  to  the  extent  of  $175,000  carry  a  part  of  this 
charge.  The  income  in  fees  is  $34,093.* 

Laboratory  facilities:  Excellently  equipped  laboratories  are  provided  for  all  the  fun- 
damental branches;  the  men  in  charge  are  productive  scientists  as  well  as  com- 
petent teachers.  There  is  a  large  library,  a  good  museum,  and  other  necessary 
teaching  aids. 

Clinical  facilities:  The  school  is  fortunate  in  the  possession  of  its  own  hospital,  every 
1  Including  laboratory  fees  paid  by  students  registered  in  the  homeopathic  department;  see  (2). 


244  MEDICAL  EDUCATION 

case  in  which  can  be  used  for  purposes  of  instruction.  A  liberal  policy  has  largely 
overcome  the  disadvantages  of  location  in  a  small  town ;  for  the  clinical  material  is  in 
the  departments  of  surgery,  psychiatry,  and  various  specialties,  of  sufficient  amount; 
it  is  fair  in  medicine,  increasing  in  obstetrics.  The  thoroughness  and  continuity 
with  which  the  cases  can  be  used  to  train  the  student  in  the  technique  of  modem 
methods  go  far  to  offset  defects  due  to  limitations  in  their  number  and  variety. 

Date  of  visit:  March,  1909. 

(2)  UNIVERSITY  OF  MICHIGAN  HOMEOPATHIC  COLLEGE.  Organized  1875.  An  organic 
department  of  the  university. 

Entrance  requirement:  A  four-year  high  school  education. 
Attendance:  80,  38  per  cent  from  Michigan. 
Teaching  staff:  26,  of  whom  15  are  professors. 

Resources  available  for  maintenance:  The  school  and  its  hospital  are  supported  by 
state  appropriations.  Its  budget  is  $16,400;  that  of  its  hospital,  $31,000.  The  in- 
come in  fees  is  $4515. 

Laboratory  facilities :  The  students  receive  their  laboratory  instruction  in  common 
with  the  students  of  the  Department  of  Medicine  and  Surgery,  despite  the  fact 
that  there  is  a  difference  of  two  years  of  college  work  in  their  preparation. 

Clinical  facilities :  The  college  has  its  own  hospital  of  about  100  beds,  where  clinical 
instruction  is  given  according  to  homeopathic  principles. 

Date  of  visit:  March,  1909. 

BATTLE  CREEK:  Population,  25,862. 

(3)  AMERICAN  MEDICAL  MISSIONARY  COLLEGE.  Organized  1895.  An  independent  in- 
stitution. A  divided  school,  part  of  the  work  being  given  in  Chicago,  part  at 
Battle  Creek.  No  year  is  given  entire  at  either  place. 

Entrance  requirement:  A  four-year  high  school  course  or  its  equivalent.  Christians  only 
are  admitted.  The  Chicago  teachers  are  all  practitioners ;  the  Battle  Creek  teachers 
are  connected  with  the  Battle  Creek  Sanitarium  as  laboratory  workers  or  physicians. 

Attendance:  75. 

Teaching-  staff:  31,  of  whom  22  are  professors,  9  of  other  grade. 

Resources  available  for  maintenance :  Income  from  endowment  of  $200,000  and  fees. 

Laboratory  facilities :  Anatomy  is  given  in  Chicago,  where  the  student  spends  six 
weeks  during  each  of  the  first  three  years  and  30  weeks  of  the  fourth  year.  The 
other  laboratory  courses  are  given  at  Battle  Creek  by  the  laboratory  men  and 
physicians  connected  with  the  Battle  Creek  Sanitarium.  Indeed,  the  school  and  the 


MICHIGAN  245 

sanitarium  are  inextricably  interwoven.  Students  assist  in  the  laboratories  and 
treatment-rooms.  Their  laboratory  training  thus  takes  on  a  decidedly  practical 
character.  But  this  has  its  disadvantages;  for  the  sanitarium  is  devoted  to  the  ap- 
plication of  certain  ideas  rather  than  to  untrammeled  scientific  investigation. 
Disciples  rather  than  scientists  are  thus  trained.  The  outfit  is  adequate  for  routine 
work,  with  abundant  practical  illustration  in  chemistry,  pathology,  bacteriology, 
and  histology.  In  physiology  and  pharmacology  the  provision  is  slighter. 

Clinked  facilities:  Of  the  last  year,  30  weeks  are  spent  in  Chicago,  where  the  students 
attend  St.  Luke's  Hospital,  one  or  two  other  institutions,  and  a  dispensary  in  the 
school  building.  For  additional  clinical  teaching  they  depend  on  Battle  Creek :  in 
the  sanitarium  they  see  an  abundance  of  chronic  and  surgical  cases;  acute  cases 
are  rare,  and  are  accessible  chiefly  when  physicians  can  ask  students  to  accompany 
them  on  their  rounds.  The  clinical  laboratory  is  closely  correlated  with  bedside 
work.  By  assisting  in  the  sanitarium  and  out,  the  student  gets  an  unusually  close 
experience  as  far  as  it  goes,  but,  once  more,  under  the  limitations  of  the  therapeutic 
theories  approved  by  the  sanitarium  authorities;  a  critical  and  investigative  spirit 
is  not  cultivated. 

The  instructors  of  the  divided  parts  of  the  school  form  practically  separate  faculties. 
Date  of  visit:  February,  1910. 

DETROIT:  Population,  393,536. 

(4)  DETROIT  COLLEGE  OF  MEDICINE.  Organized  by  merger  1885.  An  independent 
institution. 

Entrance  requirement:  A  four-year  high  school  diploma  or  its  equivalent,  actually 
enforced. 

Attendance:  161,  70  per  cent  from  Michigan  (16  per  cent  from  Canada). 

Teaching  staff:  104,  of  whom  25  are  professors  and  79  of  other  grade.  There  are 
no  full-time  teachers. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $22,000  (estimated). 

Laboratory  facilities :  The  school  is  provided  with  separate  laboratories,  each  with 
ordinary  routine  equipment,  for  the  following  subjects :  chemistry,  anatomy,  phys- 
iology, pathology,  clinical  microscopy,  histology,  and  bacteriology.  There  is  a  slight 
additional  equipment  in  the  way  of  museum,  charts,  books,  and  other  teaching  ad- 
juncts. 

Clinical  facilities :  The  school  has  access  on  the  usual  terms  to  several  hospitals,  staff 
members  of  which  hold  positions  on  the  school  faculty.  The  hospital  service  ro- 
tates every  three  months.  At  one  hospital  100  available  beds  are  perhaps  equally 


246  MEDICAL  EDUCATION 

divided  between  medicine  and  surgery;  elsewhere  surgery  greatly  predominates. 
Obstetrical  work  is  mainly  furnished  by  the  Woman's  Hospital  and  by  an  out- 
patient department  just  started.  Post-mortems  are  hard  to  get. 

The  dispensary  service  is  fair. 
Date  of  visit  .-December,  1909. 

(5)  DETROIT  HOMEOPATHIC  COLLEGE.  Organized  1899.  An  independent  school. 
Entrance  requirement:  A  four-year  high  school  course  or  its  equivalent. 
Attendance:  34. 

Teaching-  staff':  35,  of  whom  17  are  professors,  18  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  $3010  (estimated). 

Laboratory  facilities :  These  are  wretched.  There  is  an  ordinary  laboratory  for  chem- 
istry; another,  much  less  than  ordinary,  for  bacteriology.  The  pathological  room 
contained  a  few  dozen  specimens  in  utter  disorder;  the  anatomical  room  contained 
a  single  cadaver.  The  teaching-rooms  are  bare,  except  for  chairs  and  tables;  the 
building  is  poorly  kept.  The  dean  and  the  secretary  have  their  offices  "downtown." 

Clinical  facilities :  The  school  has  access  to  Grace  Hospital,  the  wards  of  which  con- 
tain 56  beds,  mostly  surgical.  Clinics  are  held  two  days  weekly.  The  hospital 
authorities  are  well  disposed  towards  the  school,  but  the  "boys  don't  take  ad- 
vantage of  their  opportunities." 

There  is  a  dispensary  at  the  school  building.  It  is  incredibly  bad.  Prescriptions 
are  found  written  on  scraps  of  paper,  unnumbered.  There  are  no  systematic  records. 
Date  of  visit :  December,  1909. 

General  Considerations 

MICHIGAN  is  fortunate  in  the  possession  of  an  alert  state  board,  which  enforces  with 
vigor  the  high  school  requirement,  and  may  perhaps  be  counted  on  to  advocate  an 
advance  of  the  state  practice  standard  to  meet  the  educational  standard  of  the  state 
university.  As  the  state  furnishes  a  thoroughly  admirable  education  at  relatively 
slight  expense,  there  is  no  reason  why  it  should  keep  the  practice  of  medicine  open 
to  low-grade  physicians,  whether  trained  within  or  without  its  borders.  Sound  policy 
would  quickly  close  the  two  homeopathic  schools  and,  in  all  probability,  the  Detroit 
College  of  Medicine.  To  the  credit  of  the  latter  institution,  however,  be  it  said  that 
its  officers  have  heartily  cooperated  with  the  state  board  in  the  enforcement  of  a 
genuine  high  school  standard. 

The  real  problem  now  agitating  the  state  concerns  the  medical  department  of  the 
state  university  at  Ann  Arbor.  The  defects  of  Ann  Arbor  as  the  seat  of  a  medical 
school  have  been  touched  on  in  these  pages.  There  is  no  question  that,  if  the  entire 
state  university  were  at  Detroit,  the  medical  department  would  be  better  off.  But 


MINNESOTA  247 

this  is  by  no  means  equivalent  to  urging  that  it  be  detached  or  split.  The  entire 
detached  school  is  now  on  trial  at  Galveston,  Indianapolis,  New  York.  It  would  be 
well  to  watch  the  outcome  of  those  experiments  before  trying  any  others.  It  is  already 
clear  that  if  a  university  department  of  medicine  is  to  be  genuinely  productive,  the 
remote  department  requires  most  generous  support ;  for  much  that  is  provided  at 
the  seat  of  the  university  for  other  departments  will  have  to  be  duplicated.  To  cre- 
ate the  university  spirit  in  a  distant  institution  is  almost  like  developing  a  second 
—  though  much  less  expensive — university. 

An  alternative  suggestion  looks  to  the  removal  to  Detroit  of  part  or  all  of  the 
clinical  instruction.  If  part  is  removed,  clinical  teachers  must  oscillate  backward  and 
forward  between  Detroit  and  Ann  Arbor.  Where  would  the  productive  clinical  teacher 
have  his  workshop  ?  Nowhere,  in  all  likelihood.  If  the  entire  clinical  department  is 
removed,  the  split  school  faces  the  conditions  we  encounter  in  Nebraska,  California, 
and  Kansas.  Once  more,  let  us  wait  for  the  successful  operation  of  one  of  these  divided 
schools  before  multiplying  unpromising  experiments.  Meanwhile,  the  state  can  by 
increased  liberality  almost  at  will  develop  the  medical  clinic  of  the  university  hos- 
pital. Agitation  in  favor  of  splitting  or  removing  it  may  proceed  from  several  con- 
siderations,— it  is  not  inspired  by  sound  scientific  or  educational  ideas. 

For,  Ann  Arbor  has  itself  proved  what  the  experience  of  Germany  had  previously 
demonstrated, — that  a  school  of  medicine  can  be  developed  in  a  small  university 
town.  The  ideals  are  there;  the  contiguous  departments  are  there;  there  is  an  ab- 
sence of  the  distractions  which  have  thus  far  proved  so  damaging  to  city  clinicians. 
A  faculty  of  distinction,  with  a  hospital  well  equipped  for  the  care  of  the  sick, 
and  for  teaching  and  research,  can  successfully  overcome  the  most  serious  diffi- 
culties of  the  situation.  The  problem  can  be  solved  by  intelligent  organization  and 
liberal  support.  Gaps  may  indeed  remain  in  the  student's  experience.  But  if  he  has 
been  well  drilled  in  technique  and  method,  his  defects  will  be  readily  cured  by  a  hos- 
pital year.  The  solution  for  Michigan  may  therefore  come,  as  has  been  proposed, 
through  an  effective  affiliation  of  the  hospitals  of  the  state  with  the  school  of  medicine 
of  the  state  university.  The  hospitals  would  profit  bya  connection  of  this  kind,  and  they 
would  assist  by  becoming  factors  in  the  education  of  the  future  physicians  of  the  state. 

MINNESOTA 

Population,  2,162,726.  Number  of  physicians,  2204.  Ratio,  1 : 981. 
Number  of  medical  schools,  1. 

MINNEAPOLIS-ST.  PAUL :  Population,  552,211. 

(1)  UNIVERSITY  OF  MINNESOTA  COLLEGE  OF  MEDICINE  AND  SURGERY.  Organized  in  1883, 
it  has  step  by  step  absorbed  all  other  medical  schools  in  the  state,  including  (1909) 
the  homeopathic  department  of  the  university.  Elective  courses  in  homeopathic 


248  MEDICAL  EDUCATION 

materia  medica  and  therapeutics  are  offered  on  condition  that  students  follow- 
ing them  shall  receive  the  degree  of  Doctor  of  Medicine  in  Homeopathy. 

Entrance  requirement:  Two  years  of  college  work,  specifically  including  the  funda- 
mental sciences  and  a  modern  language. 

Attendance :  174 ,  83  per  cent  from  Minnesota. 

Teaching  staff:  49  professors  and  71  of  other  grade, — total,  120. 

Resources  available  for  maintenance:  State  appropriations.  The  budget  calls  for 
$71,336.  The  income  from  fees  is  $16,546. 

Laboratory  facilities :  Excellent,  exceedingly  attractive,  and  well  organized  labora- 
tories are  provided  for  all  the  scientific  branches.  The  State  Laboratory  of  Pub- 
lic Health  is  practically  part  of  the  school  plant.  The  instruction  is  in  charge  of 
full-time  teachers,  generously  supplied  with  books,  apparatus,  and  material. 

Clinical  facilities :  The  school  has  hitherto  relied  on  the  municipal  hospitals  and  un- 
paid clinical  teachers,  with  the  usual  results.  Teaching  opportunities  were  both  lim- 
ited in  extent  and  precarious  in  character.  These  institutions  are  in  fact  not  organ- 
ized, equipped,  or  conducted  with  educational  requirements  in  mind.  An  appropria- 
tion has  now  been  made  to  build  a  teaching  hospital ;  and  a  small  temporary  hos- 
pital has  been  started.  Simultaneously,  the  clinical  teaching  has  been  reorganized 
by  placing  the  chiefs  in  medicine  and  surgery  respectively  on  salaries  that  com- 
mand the  interest  and  effort  of  active  teachers.  The  same  policy  must  be  applied 
generally  throughout  the  clinical  department. 

The  dispensary,  well  attended  and  long  loosely  conducted,  has  recently  been  re- 
constructed along  the  same  lines. 

Date  ofvifit :  May,  1909. 

General  Considerations 

MINNESOTA  is  perhaps  the  first  state  in  the  Union  that  may  fairly  be  considered  to 
have  solved  the  most  perplexing  problems  connected  with  medical  education  and  prac- 
tice except  as  to  osteopathy.  It  has  indeed  still  to  realize  its  plans  for  an  adequate 
clinical  establishment  of  modern  character;  but  there  is  little  doubt  that  this  is  only 
a  question  of  time, — and  of  a  short  time,  at  that.  Meanwhile  medical  education  has, 
with  the  active  cooperation  of  the  state  board,  been  concentrated  in  the  hands  of  the 
university,  fortunately  situated  in  the  heart  of  the  largest  community  of  the  state ; 
the  state  has  got  rid  of  rival  schools,  regular  and  sectarian,  the  latter  by  a  perfectly 
fair  provision  for  separate  instruction  in  sectarian  dogmas  for  any  student  who  is  will- 
ing to  accept  a  diploma  qualified  so  as  to  mark  that  fact.  Since  all  else — anatomy, 
physiology,  surgery — are  common  to  and  the  same  for  all "  schools  "  of  medicine,  there 
is  one  standard  of  admission  to  the  department,  one  quality  of  instruction,  one  exami- 
nation for  the  degree  for  all  alike.  Finally,  the  educational  preliminary  qualification  of 


MISSISSIPPI  249 

the  state  medical  school  has  become  the  practice  preliminary  of  the  state.  In  future, 
any  person  desiring  to  practise  medicine  in  Minnesota  must  get  as  good  an  education 
— preliminary  and  professional — as  the  state  furnishes  and  requires  of  its  own  sons  : 
a  regulation  both  fair  and  wise,  whether  viewed  from  the  standpoint  of  the  student 
or  from  the  broader  standpoint  of  public  interest,  to  which  all  else  is  properly 
subordinate.  Henceforth,  the  success  of  the  school  will  depend  largely  on  the  gener- 
osity of  the  state  in  developing  the  clinical  teaching,  and  on  the  character  of  the 
hospital  and  dispensary  which  it  organizes  with  that  in  view. 


MISSISSIPPI 

Population,  1,786,773.  Number  of  physicians,  2054.  Ratio,  1 :  887. 
Number  of  medical  schools,  2. 

MERIDIAN :  Population,  22,415. 

(1)  MISSISSIPPI  MEDICAL  COLLEGE.  Organized  1906.  A  stock  company. 
Entrance  requirement :  Nominal. 

Attendance:  100,  94  per  cent  from  Mississippi. 

Teaching  staff:  19,  of  whom  12  are  professors,  7  of  other  grade. 

Resources  available  for  maintenance :  Fees,  amounting  to  87500  (estimated). 

Laboratory  facilities :  At  the  date  of  visit,  there  was  no  outfit  at  all.  Subsequent 
reliable  report  credits  the  school  with  a  vat  containing  four  cadavers  in  a  room 
without  other  contents,  a  simple  outfit  for  elementary  chemistry,  and  twenty  brand- 
new  microscopes,  but  no  material  to  use  with  them. 

Clinical  facilities :  Practically  none.  Some  of  the  faculty  have  places  on  the  staff  of  a 
small  hospital  over  a  mile  distant. 

There  is  no  dispensary. 
Date  of  visit :  January,  1909. 

OXFORD-VICKSBURG:  (Population:  Oxford,  2104;  Vicksburg,  16,800). 

(2)  UNIVEBSITY  OF  MISSISSIPPI,  MEDICAL  DEPARTMENT.1  A  divided  school.  First  half 
organized  1903;  second  half  organized  1909.  An  organic  part  of  the  university. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent.  Over 
one-half  of  this  year's  entering  class  had  had  two  or  more  years  of  college  work. 

Attendance :  39. 

1  As  this  report  goes  to  press,  it  is  announced  that  the  clinical  end  of  this  school  (at  Vicksburg)  is 
discontinued.  The  first  two  years  will  continue  to  be  given  at  Oxford. 


250  MEDICAL  EDUCATION 

Teaching  staff:  At  Oxford,  8  professors,  3  of  whom  give  entire  time  to  this  depart- 
ment, and  3  assistants ;  at  Vicksburg,  6  professors  and  10  of  other  grade. 

Resources  available  for  maintenance :  The  department  shares  the  general  funds  of  the 
university.  Its  budget  calls  for  $15,000.  Fees  amount  to  $3500. 

Laboratory  facilities :  (Oxford.)  Laboratories,  adequate  to  the  needs  of  the  instruc- 
tion offered,  are  provided  for  physiology,  pharmacology,  histology,  and  anatomy ; 
pathology  and  bacteriology  are  less  satisfactory.  Chemistry  is  well  cared  for  in 
the  university  laboratory.  The  teachers  need  a  larger  number  of  competent  as- 
sistants and  helpers;  a  beginning  has  been  made  towards  a  departmental  library. 

Clinical  facilities :  (Vicksburg.)  The  clinical  end  has  been  so  recently  started  that  no 
attempt  will  be  made  here  to  deal  with  it.  It  will  probably  be  discontinued. 

Date  ofvitit:  November,  1909. 

General  Considerations 

OF  the  two  schools,  that  at  Meridian  is  without  merit.  At  a  time  when  the  state  has 
already  more  doctors  than  it  needs,  the  starting  of  a  didactic  school,  conducted  by 
the  local  practitioners  of  a  small  town,  is  absolutely  unjustifiable.  The  state  laws 
ought  to  be  promptly  amended  so  as  to  make  such  ventures  impossible. 

The  state  is  indeed  not  favorably  situated  for  the  entire  training  of  its  own  doctors. 
The  state  university,  the  only  institution  to  which  the  task  could  fall,  is  unfortunately 
located.  Its  present  experiment  with  a  divided  school  is  even  more  problematical  than 
similar  ventures  elsewhere;  for  to  the  inherent  disadvantage  of  division  is  to  be  added 
the  fact  that  Vicksburg  itself  is  a  small  town.  Moreover,  the  first  half  of  the  school,  at 
Oxford,  though  distinctly  creditable,  is  far  from  satisfying  its  faculty.  It  is  a  ques- 
tion whether  the  university  would  not  do  more  wisely  to  concentrate  its  outlay  on 
the  Oxford  branch. 

Up  to  this  time,  the  medical  profession  of  Mississippi  has  been  educated  mainly 
in  the  proprietary  schools  of  the  southern  states.  It  would  be  fortunate  indeed  if 
henceforth  its  members  should  get  at  least  their  first  two  years  at  Oxford.  To  make 
itself  the  main  factor  in  the  education  of  the  physicians  of  the  state,  the  university 
should  keep  its  entrance  requirement  in  touch  with  the  secondary  school  system.  Its 
present  and  prospective  facilities  do  not  really  warrant  a  higher  requirement.  Besides, 
it  can  perform  a  more  useful  service  by  training  a  relatively  large  body  of  students 
at  the  high  school  level  than  by  training  a  few  on  a  higher  standard.  McGill  and 
Toronto  do  not  prove  that  a  high  school  standard  is  as  good  as  a  college  standard ; 
but  they  do  prove  that  where  a  high  school  standard,  or  even  less,  is  enforced,  well 
chosen  teachers,  well  equipped  and  liberally  sustained  laboratories,  are  capable  of 
producing  a  very  useful  type  of  physician.  The  present  duty  of  the  southern  state 
universities  is  not  to  press  prematurely  to  a  standard  that  either  cannot  be  enforced 
or  that,  if  enforced,  will  relegate  the  main  army  of  students  to  medical  schools  with- 


MISSOURI  251 

out  either  facilities  or  ideals,  but  to  endeavor  themselves  to  get  hold  of  a  sufficient 
body  of  students  to  meet  the  demand  on  an  enforceable  basis,  to  improve  their  facilities 
so  that  this  number  can  be  well  trained,  and  to  urge  the  legislature  to  make  their 
standard  the  practice  standard  of  their  respective  states.  Under  more  favorable  cir- 
cumstances, a  decade  hence,  the  state  can  and  should  ask  more.  But  just  now  it  is 
more  important  to  develop  the  medical  department  of  the  state  university  at  the 
high  school  level  than  to  push  it  higher,  leaving  the  training  of  southern  physicians 
to  schools  without  ideals  or  resources. 


MISSOURI 

Population,  3,491,397.  Number  of  physicians,  6323.  Ratio  1 :  552. 
Number  of  medical  schools,  12  {plus  1  postgraduate  school). 

COLUMBIA:  Population,  7302. 

(1)  UNIVERSITY  OF  MISSOURI  SCHOOL  OF  MEDICINE.  A  two-year  school.  Organized  1872. 
An  organic  department  of  the  university. 

Entrance  requirement:  One  year  of  college  work. 

Attendance:  47,  all  from  Missouri. 

Teaching  staff':  14,  8  being  professors,  6  of  other  grade. 

Resources  available  for  maintenance:  The  department  shares  the  general  income  of 
the  university.  Its  budget  calls  for  $31,000;  fees  amount  to  $2820. 

Laboratory  facilities:  The  medical  department  occupies  a  new  and  well  equipped 
building,  excellently  adapted  to  its  purposes.  The  teaching  is  in  charge  of  full- 
time  instructors  of  modern  training  and  ideals.  A  university  hospital  of  45  beds 
gives  the  department  the  advantage  of  clinical  material  and  connection,  even  though 
the  actual  instruction  is  limited  to  the  work  of  the  first  two  years,  a  feature  of 
great  importance.  There  is  a  library,  supplied  with  important  current  periodicals, 
domestic  and  foreign. 

Date  of  visit:  April,  1909. 

KANSAS  CITY:  Population,  205,022  (plus  Kansas  City,  Kan.,  81,052). 

(2)  UNIVERSITY  MEDICAL  COLLEGE.  Organized  1881.  An  independent  institution. 
Entrance  requirement:  Less  than  a  high  school  education. 

Attendance:  174,  82  per  cent  from  Missouri  and  Kansas. 

Teaching  staff:  65,  30  being  professors,  35  of  other  grade.  There  is  one  full-time 
teacher. 


252  MEDICAL  EDUCATION 

Resources  available  for  maintenance:  Fees,  amounting  to  $17,600  (estimated). 

Laboratory  facilities:  A  single  large  laboratory  is  set  aside  for  chemistry  of  all  kinds, 
and  urinalysis:  huge  bottles  are  furnished  instead  of  separate  reagent  sets;  his- 
tology, pathology,  and  bacteriology  occupy  a  second  room,  equipped  for  routine 
work  in  each  of  these  branches.  Physiology  is  similarly  provided  for.  There  is  the 
usual  dissecting-room,  large,  clean,  and  well  lighted.  There  are  no  books.  There 
is  a  small  museum  and  a  large  supply  of  pathological  material. 

Clinical  facilities:  Adjoining  the  school  is  the  University  Hospital,  most  of  the  work 
of  which  is  surgery ;  but  as  there  are  no  free  beds,  it  is  of  no  real  use  to  students. 
The  main  reliance  for  clinical  instruction  is  the  City  Hospital,  a  beautiful  modern 
structure,  in  which  clinics  are  held,  mainly  in  the  amphitheater,  one  day  weekly 
from  8  to  12.  The  school  has  no  access  to  the  clinical  laboratory,  to  autopsies, 
obstetrics,  or  infectious  diseases,  but  an  out-patient  department  and  a  Rescue 
Home  furnish  obstetrical  opportunity  in  abundance.  Other  institutions  furnish 
additional  material.  The  school  dispensary — fairly  clean — has  a  large  attendance; 
but  it  is  poorly  equipped  and  loosely  conducted.  The  clinical  facilities  are,  there- 
fore, unsatisfactory  in  both  quality  and  extent. 

Date  of  virit :  November,  1909. 

(3)  KANSAS  CITY  HAHKEMANN  MEDICAL  COLLEGE.  Homeopathic.  Organized  1888,  an 
independent  institution. 

Entrance  requirement:  Less  than  a  high  school  education. 

Attendance:  59. 

Teaching  staff:  41,  of  whom  33  are  professors,  8  of  other  grade. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $5900  (estimated). 

Laboratory  facilities:  All  laboratory  work  is  conducted  by  one  teacher,  who  serves 
in  the  same  capacity  in  the  local  eclectic  and  osteopathic  schools.  The  chemical 
laboratory  is  small  and  poor;  that  for  pathology,  histology,  bacteriology,  and  em- 
bryology, urinalysis  and  blood  work  combined,  is  worse — meagerly  equipped  and  in 
utter  disorder.  Anatomy  had  not  as  yet  started  (November).  There  are  a  few  books. 

Clinical  facilities:  Amphitheater  instruction  is  given  one  morning  a  week  at  the 

City  Hospital. 

In  the  school  building  is  a  small  dispensary,  with  an  estimated  attendance  of 

6  or  7  a  day.  A  neatly  kept  card  index  is  employed. 
Dot*  ofvitti:  November,  1909. 

(4)  CENTEAL  COLLEGE  OF  OSTEOPATHY.  Established  1902.  An  independent  institution. 
Entrance  requirement:  Nominal. 


MISSOURI  253 

Attendance:  40. 

Teaching  staff*:  20. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $4500  (estimated). 

Laboratory  facilities:  Practically  none  at  all:  hopelessly  meager  appointments  in  two 
rooms  are  denominated  respectively  chemical  and  pathological  laboratories.  Dissec- 
tion was  not  in  progress  at  the  time  of  the  visit.  It  is  held  that  "students  ought 
to  know  anatomy  before  they  dissect, — they  get  more  out  of  it."  A  single  cadaver 
was  dissected  in  September  and  October;  another  was  expected  in  February. 

Clinical  facilities:  A  pay-dispensary  is  operated,  senior  students  giving  "treatments" 
to  patients  who  pay  three  dollars  a  month.  Students  may  on  payment  of  fee  attend 
public  clinics  at  the  City  Hospital,  but  the  school  has  no  hospital  facilities  or 
connections  of  its  own  at  all. 

Date  of  visit:  November,  1909. 

KIRKSVILLE:  Population,  8422. 

(5)  AMERICAN  SCHOOL  OF  OSTEOPATHY.  Established  1892  and  owned  by  two  individ- 
uals. 

Entrance  requirement:  Less  than  a  common  school  education. 

Attendance:  560  (ranging  in  age  from  18  to  54  years). 

Teaching  staff":  12,  with  11  student  assistants. 

Resources  available  for  maintenance:  Fees,  amounting  to  $89,600  (estimated). 

Laboratory  facilities:  These  are  absurdly  inadequate  for  the  number  of  students,  as 
is  likewise  the  teaching  staff.  A  single  room,  with  a  corresponding  preparation 
room,  is  used  as  bacteriological  and  physiological  laboratory,  a  six  weeks'  course 
being  given  by  one  teacher  to  successive  squads  of  32.  In  the  same  way  separate 
additional  laboratories  are  provided  for  chemistry,  anatomy,  and  pathology.  Ma- 
terial for  pathological  demonstration  is  bought;  there  is  no  museum,  and  no  effort 
is  made  to  save  gross  material.  The  dissecting-room  is  foul.  The  "professors"  in 
charge  of  histology,  pathology,  and  bacteriology  are  senior  students. 

Clinical  facilities:  A  hospital  of  54  beds  adjoins,  but  its  work  is  practically  all 
"surgery;"  the  ward  cases  are  "occasionally  used  for  clinics.  Students  witness 
operations."  Obstetrical  work  is  comparatively  scanty.  There  is  no  other  hospital 
in  the  town. 

A  large  dispensary  is  operated.  An  instructor  is  at  hand  the  first  time  the  stu- 
dent administers  a  "treatment;'1  after  that,  "only  if  summoned."  A  course  of 
twenty  lectures  on  the  fallacies  of  medicine  is  given,  so  that  the  graduate  will 
know  why  he  does  not  use  "drugs." 


254  MEDICAL  EDUCATION 

The  school  is  a  business  in  which  a  large  margin  of  profit  is  secured  by  its  owners. 

The  teaching  furnished  is  of  the  cheapest  kind.  Its  huge  income  is  therefore  largely 

profit. 

Date  of  visit:  November,  1909. 

ST.  JOSEPH:  Population,  132,954. 

(6)  ENSWORTH  MEDICAL  COLLEGE.  Organized  in  1876,  it  has  twice  merged  with  other 
schools.  An  independent  institution. 

Entrance  requirement:  Less  than  a  four-year  high  school  education. 

Attendance:  72,  68  per  cent  from  Missouri. 

Teaching  staff:  Numbers  40,  32  being  professors,  8  of  other  grade. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $7060  (estimated). 

Laboratory  facilities :  These  are  very  weak.  The  chemical  laboratory  is  of  elementary 
character;  there  is  a  small  outfit  for  physiological  demonstration;  a  single  room 
with  little  material  is  provided  for  pathology,  bacteriology,  and  histology.  There 
is  the  usual  ill  kept  dissecting-room.  There  is  no  museum,  books,  or  teaching  ac- 
cessories. The  building  is  very  dirty. 

Clinical  facilities:  These  are  wholly  inadequate.  The  adjoining  hospital,  containing 
six  free  beds,  is  of  little  use.  Fifty  beds,  of  which  14  were  occupied  at  the  time  of 
visit,  are  accessible  at  a  Catholic  institution,  but  four-fifths  of  its  work  is  surgical. 
Obstetrical  work  is  entirely  inadequate;  post-mortems  are  very  rare.  The  available 
material,  scant  as  it  is,  is  poorly  used,  as  far  as  teaching  is  concerned. 

There  is  a  small  dispensary,  without  records,  organization,  or  equipment. 

Date  of  visit:  November,  1909. 

ST.  LOUIS:  Population,  698,706. 

(7)  WASHINGTON  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1842.  United  in 
1891  with  Washington  University,  of  which  it  has  been  since  1907  an  organic 
department.  Completely  reorganized  on  modern  lines  1910. 

Entrance  requirement:  Four-year  high  school  education.  Credentials  are  passed  on 
and  examinations  conducted  by  the  university. 

Attendance:  178,  60  per  cent  from  Missouri. 

Teaching  staff:  99,  48  being  professors,  51  of  other  grade.  There  had  been  four  full- 
time  professors  and  a  few  full-time  assistants,  but  as  this  report  goes  to  press,  the 
entire  faculty  is  undergoing  reconstitution.  All  the  laboratory  branches,  as  well  as 
the  departments  of  medicine,  surgery,  and  pediatrics,  have  been  already  reorganized 
on  a  strict  university  basis. 


MISSOURI  255 

Resources  available  for  maintenance:  The  school  shares  the  general  funds  of  Wash- 
ington University.  Its  fee  income  is  $21,000;  its  budget  (1909-10)  $51,265,  (not 
including  $30,000  spent  on  the  University  Hospital).  Productive  endowments  to 
the  extent  of  $1,500,000  will  become  available  in  1910-11. 

Laboratory  facilities:  These  have  hitherto  sufficed  for  only  routine  work  in  the  fun- 
damental branches,  but  the  reorganization  on  productive  modern  lines,  already 
under  way,  will  shortly  be  completely  effected.  The  museum,  though  small,  is  good ; 
a  start  towards  a  modern  medical  library  has  been  made. 

Clinical  facilities:  The  school  has  its  own  hospital  of  98  beds,  one-fourth  of  them  free; 
and  has  access  to  other  hospitals  on  the  usual  footing.  The  amount  of  material  thus 
available  was  fair;  but  the  close  affiliation  which  has  been  made  with  the  trustees 
of  the  Barnes  and  the  Children's  Hospitals  revolutionizes  the  clinical  situation  of 
the  school. 

The  school  controls  two  dispensaries, — one  connected  with  the  University  Hos- 
pital, the  other  situated  in  the  medical  school  building.  Their  combined  atten- 
dance is  very  large. 

Date  ofvitit:  April,  1909. 

(8)  ST.  Louis  UNIVERSITY.  The  school,  organized  1901  by  merger,  was  in  1903  pur- 
chased for  cash  by  the  university,  of  which  it  is  now  an  organic  part. 

Entrance  requirement:  Less  than  a  high  school  education. 
Attendance:  243,  42  per  cent  from  Missouri. 

Teaching  staff:  121,  39  being  professors,  82  of  other  grade.  There  are  six  full-time 
instructors  with  competent  helpers;  but  the  assistants  are  as  a  rule  students. 

Resources  available  for  maintenance:  Fees,  amounting  to  $26,630  (estimated),  supple- 
mented by  small  allotment  from  the  university  treasury.  During  a  period  of  seven 
years  (1903-10),  the  university  devoted  $40,817  to  its  medical  school.  $20,000 
have  been  recently  subscribed  towards  an  endowment  fund  for  the  department. 

Laboratory  facilities :  Excellent  teaching  laboratories  are  provided  for  all  the  funda- 
mental branches,  in  addition  to  which  provision  has  been  made  for  research  in 
several  directions. 

Clinical  facilities :  The  school  has  a  small  hospital  of  its  own  (12-16  free  beds),  and 
has  access  on  the  usual  terms  to  several  other  institutions.  The  material,  while  fair 
in  amount,  is  scattered  and  under  imperfect  control.  The  hospitals  used  are  not  or- 
ganized, equipped,  or  conducted  with  a  view  to  the  requirements  of  modern  medi- 
cal teaching. 

The  dispensary  is  fair. 

Date  of  visit:  April,  1909. 


256  MEDICAL  EDUCATION 

(9)  ST.  Louis  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  1869.  An  independent 
institution. 

Entrance  requirement:  Nominal. 

Attendance:  224. 

Teaching  staff:  49,  of  whom  25  are  professors,  24  of  other  grade. 

Resources  available  for  maintenance :  Fees  only,  amounting  to  $16,035  (estimated). 

Laboratory  facilities:  The  school  occupies  a  badly  kept  building,  the  inner  walls  cov- 
ered with  huge  advertisements.  A  single  ordinary  laboratory  is  provided  for  chem- 
istry ;  there  is  a  make-believe  laboratory  for  experimental  physiology ;  for  the  school 
owns  the  equipment  stipulated  by  the  state  board,  though  the  dust-covered  tables 
do  not  indicate  use.  Rows  of  empty  reagent  bottles  are  also  to  be  seen.  The  "  mu- 
seum" consists  of  some  cheap  photographs  and  drawings  and  a  few  badly  preserved 
wet  specimens, — all  carefully  arranged  so  as  to  occupy  as  much  space  as  possi- 
ble. Microscopes  appear  to  indicate  a  laboratory  of  pathology  or  bacteriology; 
but  the  "individual  lockers"  were  empty.  It  was  explained  that  "students  have 
to  bring  slides,  holders,  and  cover-glasses  with  them,  for  they  furnish  their  own 
and  keep  them  at  home."  Anatomy  was  "over" — only  empty  tables  were  found  in 
the  dissecting-room,  the  sole  access  to  which  is  by  way  of  a  fire-escape. 

Clinical  facilities :  A  small,  poorly  lighted,  badly  ventilated,  and  overcrowded  hospi- 
tal is  part  of  the  school  building.  Its  operating  amphitheater  is  good.  Clinics  of 
slight  value  are  also  held  at  the  City  Hospital.  A  few  other  opportunities  of  infe- 
rior importance  are  obtained  in  the  usual  way. 

A  dark  and  dingy  suite  of  rooms  serves  for  a  dispensary.  The  room  devoted  to 
gynecology,  for  instance,  is  without  a  window,  and  contains  no  equipment  except 
a  deal  table  covered  with  a  sheet. 

The  school  is  one  of  the  worst  in  the  country. 
Date  of  visit:  April,  1909. 

(10)  BARNES  MEDICAL  COLLEGE.  Organized  1892.  An  independent  institution. 
Entrance  requirement:  Less  than  a  high  school  education. 

Attendance:  124. 

Teaching  staff:  64,  of  whom  39  are  professors,  25  of  other  grade. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $12,400  (estimated). 

Laboratory  facilities :  A  huge  "chemical  laboratory,  the  largest  in  the  world  devoted 
to  medical  education,"  is  the  most  striking  feature;  its  equipment  suffices  for  ele- 
mentary work  only;  another  large  room  with  ordinary  equipment  is  devoted  to 
bacteriology,  histology,  and  pathology.  A  physiological  laboratory  is  equipped 


MISSOURI  257 

in  literal  compliance  with  the  state  board  stipulations.  The  dissecting-room  is 
spacious  and  well  lighted.  There  is  no  museum;  few  books  and  few  teaching 
accessories. 

Clinical  facilities :  These  are  wholly  inadequate.  The  Centenary  Hospital,  adjoin- 
ing the  school,  is  without  educational  importance.  Its  work  is  mainly  private  and 
almost  altogether  surgical.  The  school  has  access  to  the  City  Hospital,  too,  but  its 
clinics,  held  one  afternoon  a  week,  are  of  little  value. 

The  college  buildings  contain  a  suite  of  rooms  used  as  a  dispensary.  A  consid- 
erable attendance  is  claimed,  but  the  arrangements  are  shockingly  bad.  The  rooms 
are  in  poor  condition  and  almost  devoid  of  proper  equipment. 

Date  of  visit :  April,  1909. 

(11)  AMERICAN  MEDICAL  COLLEGE.  Eclectic.  Organized  1873.  An  independent  school. 
Entrance  requirement:  Nominal. 

Attendance .-28. 

Teaching  staff:  28,  of  whom  25  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $3801  (estimated). 

Laboratory  facilities :  Meager  equipment  is  provided  for  anatomy,  chemistry,  pa- 
thology, and  bacteriology.  A  small  amount  of  apparatus  for  physiology  demonstra- 
tion, as  required  by  the  state  board,  is  displayed  in  a  case.  There  is  no  suggestion 
of  use. 

Clinical  facilities  are  equally  scanty.  A  weekly  clinic  can  be  held  at  the  City  Hos- 
pital; the  rest  depends  on  the  professor's  connections. 

A  dispensary  room  is  also  provided,  and  "almost  every  day  some  one  comes." 

Date  of  visit:  April,  1909. 

(12)  HIPPOCRATEAN  COLLEGE  OF  MEDICINE.  A  night  school.  An  independent  institu- 
tion, in  its  third  year. 

Entrance  requirement:  Nominal. 

Attendance:  31. 

Teaching  staff:  30  professors,  8  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $3315  (estimated). 

Laboratory  facilities:  A  brand-new  outfit  is  visible  in  the  shape  of  a  few  microscopes, 
physiological  apparatus,  chemical  reagents,  etc.  But  though  two  classes  were  in 
session,  none  of  the  equipment  was  in  use,  nor  did  its  appearance  indicate  previ- 
ous use.  One  of  the  classes  mentioned  was  receiving  eloquent  didactic  instruction 
in  osteology,  the  other  in  anesthesia. 


258  MEDICAL  EDUCATION 

Clinical  facilities:  Being  not  yet  needed,  these  are  not  yet  arranged  for. 
Lat«  of  vint:  April,  1909. 

KANSAS  CITY: 

(13)  POSTGRADUATE  HOSPITAL  SCHOOL.  This  institution  has  a  hospital  of  25  ward 
beds,  containing  15  patients, — 2  medical,  13  surgical.  There  were  no  students  in 
attendance  at  the  date  of  the  visit.  The  institution  is  really  a  private  hospital,  but 
incorporation  as  a  school  gives  its  faculty  privileges  at  the  City  Hospital. 

Date  ofvitit:  April,  1909. 

General  Considerations 

MEDICAL  education  in  Missouri  is  at  a  low  ebb.  The  state  board  lacks  authority  to 
enforce  even  a  high  school  preliminary, — the  more  regrettable  as,  under  the  stimu- 
lating influence  of  the  state  university,  an  excellent  high  school  system  has  been 
developed.  Missouri  is  therefore  in  the  attitude  of  requiring  every  boy  and  girl  who 
wishes  to  attend  the  state  university  to  spend  four  years  in  good  secondary  schools 
supported  by  the  people,  but  men  and  women  who  are  charged  to  safeguard  public 
health  may  attend  medical  schools  chartered  by  the  state  without  the  assurance  of 
any  definite  training  whatever.1  In  consequence,  the  state  is  badly  overcrowded 
with  practitioners  trained  in  poor  schools,  and  still  maintains  some  of  the  poorest 
schools  in  the  country.  Utterly  wretched  are  (1)  Kansas  City  Hahnemann  Medi- 
cal College,  (2)  Central  College  of  Osteopathy,  (3)  American  School  of  Osteopathy 
(Kirksville),  (4)  St.  Louis  College  of  Physicians  and  Surgeons,  (5)  American  Medical 
College,  (6)  Hippocratean  College  of  Medicine;  feeble  and  without  promise  are 
(7)  Barnes  Medical  College,  (8)  Ensworth  Medical  College,  and  (9)  University  Medical 
College,  though  the  last  named  is  distinctly  superior  to  the  other  eight.  There  re- 
main the  two-year  school  conducted  by  the  state  university,  the  medical  department 
of  Washington  University,  and  the  St.  Louis  University  School  of  Medicine. 

There  are  in  the  state  of  Missouri  fifty-odd  academic  institutions,  of  which  only 
two  have  resources  adequate  to  support  medical  schools,  viz.,  the  state  university  and 
Washington  University.  Of  the  several  towns  in  the  state  capable  of  supplying  clin- 
ical material,  only  one — St.  Louis — contains  a  strong  resident  university.  Wash- 
ington University,  St.  Louis,  is  therefore  at  this  writing  marked  out  as  the  natural 
patron  of  medical  education  in  Missouri. 

Its  importance  is  bound  to  be  more  than  local.  Aside  from  its  obvious  possibili- 
ties as  a  productive  scientific  center,  Washington  University  must  be  the  main  fac- 
tor in  the  training  of  physicians  for  the  southwest  country;  the  city  of  St.  Louis 
has  in  this  section  an  even  clearer  opportunity  than  has  Chicago  in  the  middle  west, 
New  York  in  the  east,  or  Boston  in  New  England.  For  there  is  no  other  large  city 

1  That  is  what  a  certificate  from  a  county  school  commissioner  amounts  to,  no  matter  what  it  pre- 
tends to  certify. 


NEBRASKA  259 

south  of  Minneapolis  or  as  far  west  as  the  Pacific  which  as  completely  meets  all  the 
requirements  of  the  case. 

There  is  abundant  evidence  to  indicate  that  those  interested  in  Washington  Uni- 
versity appreciate  its  "manifest  destiny ;"  it  bids  fair  shortly  to  possess  faculty, 
laboratories,  and  hospital  conforming  in  every  respect  to  ideal  standards.  It  is,  how- 
ever, worth  asking  whether  it  may  not  supplement  its  own  resources  by  some  form 
of  cooperation.  The  state  university  formerly  conducted  a  four-year  school  at  Colum- 
bia; realizing  that  its  clinical  instruction  could  not  without  immense  expenditure 
be  brought  to  the  present  level  of  the  scientific  years,  it  has  had  the  wisdom  and 
courage  to  confine  its  efforts  to  the  first  two  years.  The  easy  expedient  of  a  clinical 
end  at  Kansas  City  or  elsewhere,  it  has  with  equal  wisdom  and  firmness  rejected.  Its 
resources  and  influence,  however,  may  not  impossibly  be  enlisted  in  behalf  of  the 
medical  work  of  Washington  University,  for  the  latter  institution  is  in  position  to 
use  effectively  whatever  can  be  placed  at  its  disposal.  Should  St.  Louis  University 
receive  financial  support  enabling  it  to  enforce  the  same  entrance  standard  as  the 
other  two  institutions  mentioned,  it  also  would  be  wise  to  forego  clinical  instruction, 
turning  over  its  students  in  their  last  two  years  to  Washington  University.  A  sec- 
ond clinical  establishment  on  the  same  scale  is  neither  desirable  nor  likely.  Nor  will 
St.  Louis  University  or  its  students  be  permanently  satisfied  with  an  old-fashioned 
clinical  department  superposed  on  its  modern  laboratory  foundation. 


NEBRASKA 

Population,  1,069,579.  Number  of  physicians,  1776.  Ratio,  1:  602. 
Number  of  medical  schools,  3. 

LINCOLN-OMAHA:  (Population:  Lincoln,  53,667;  Omaha,  including  South 
Omaha,  164,519). 

(1)  COLLEGE  OF  MEDICINE,  UNIVERSITY  OF  NEBRASKA.  Organized  1881.  Affiliated  in 
1902  with  the  state  university,  of  which  it  is  now  an  organic  part.  A  divided  school, 
the  first  two  years  being  given  at  the  university  (Lincoln),  the  last  two  at  Omaha. 

Entrance  requirement:  Two  years  of  college  work. 
Attendance:  122. 

Teaching  staff':  84,  of  whom  38  are  professors,  46  of  other  grade.  The  laboratory 
branches  are  taught  by  full-time  teachers,  using  in  the  main  student  or  practitioner 
assistants. 

Resources  available  for  maintenance:  The  department  is  supported  by  state  appro- 
priations. Its  income  in  fees  for  the  year  ending  June,  1909,  was  $4905;  its  budget 
amounts  to  $20,612,  reckoning  only  items  due  directly  to  the  medical  department. 


260  MEDICAL  EDUCATION 

Laboratory  facilities :  (Lincoln.)  The  department  has  the  necessary  laboratories,  on 
the  whole  fairly  equipped.  The  instructors  are  active  men  of  modern  training, 
eager  to  do  research  work.  They  are,  however,  in  position  to  accomplish  little  in 
this  direction  for  lack  of  space,  proper  assistance,  and  funds.  The  opportunities 
are  nevertheless  adequate  for  good  routine  undergraduate  teaching.  Animals  are 
provided  in  abundance;  there  is  a  good  library  and  a  fair  collection  of  necessary 
teaching  adjuncts. 

Clinical  facilities:  (Omaha.)  The  school  has  the  privilege  of  the  County  Hospital  for 
half  the  year,  and  staff  privileges  at  the  Methodist  Hospital  and  several  other  in- 
stitutions. These  institutions  are,  of  course,  not  equipped  or  conducted  with  regard 
to  teaching.  For  example,  the  clinical  pathologist  of  the  school  is  not  now  a  mem- 
ber of  the  staff  of  either  institution;  in  consequence  of  which  fact,  the  teaching  of 
this  important  branch  is  isolated.  Section  visits  are,  however,  arranged.  There  is 
little  scientific  intercourse  or  pedagogical  interplay  between  the  severed  laboratory 
and  clinical  ends  at  Lincoln  and  Omaha  respectively. 

The  dispensary  has  a  fair  attendance,  but  is  not  well  organized. 

Date  ofviiit:  April,  1909. 

(2)  LINCOLN  MEDICAL  COLLEGE.  Eclectic.  Organized  1890.  Nominally  the  medical  de- 
partment of  Cotner  University. 

Entrance  requirement:  Nominal. 

Attendance:  42,  77  per  cent  from  Nebraska. 

Teaching  staff:  34,  all  of  whom  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $3794  (estimated). 

Laboratory  facilities :  There  are  practically  no  laboratory  facilities  beyond  a  separate 
room  set  aside  for  dissecting  and  the  meager  chemical  laboratory  of  Cotner  Univer- 
sity. Some  little  microscopical  work  may  also  be  carried  on  at  the  latter  institution. 

Clinical  facilities:  There  are  no  definite  clinical  opportunities,  not  even  a  dispensary. 
Date  ofvirit:  April,  1909. 

OMAHA 

(3)  JOHN  A.  CREIGHTON   MEDICAL  COLLEGE.  Organized   1892.  Integral  part  of 
Creighton  University. 

Entrance  requirement:  Less  than  a  four-year  high  school  education. 
Attendance:  175. 

Teaching  staff":  49,  28  of  whom  are  professors,  21  of  other  grade.  One  teacher  de- 
votes his  entire  time  to  medical  instruction. 


NEW  ENGLAND  261 

Resources  available  for  maintenance:  Mainly  fees,  amounting  to  $17,850  (estimated). 

Laboratory  facilities :  Student  laboratories,  with  individual  equipment  adequate  to 
routine  instruction,  are  provided  for  chemistry,  pathology,  histology,  and  bacteri- 
ology; the  professors  of  the  last  three  subjects  have  private  laboratories  besides. 
The  provision  for  anatomy  is  poor;  it  comprises  an  ordinary  dissecting-room  and 
a  lecture-room,  equipped  with  a  papier-mache  model,  charts,  a  defective  skeleton, 
and  some  odds  and  ends  of  bones.  The  outfit  for  experimental  physiology  and  phar- 
macology is  small.  Animals  are  obtained  as  needed.  There  is  a  small  museum  and  a 
small  library.  Quiz-compends  are  sold  on  the  premises. 

Clinical  facilities:  The  school  has  access  to  several  hospitals  where  clinical  material 
is  obtained.  Its  use  is  subject  to  the  customary  limitations.  The  main  hospital  is 
two  miles  from  the  school.  Though  90-100  beds  are  there  available  for  ward  teach- 
ing, students  cannot  work  in  the  clinical  laboratory  of  the  hospital.  Opportunities 
at  the  other  hospitals  are  not  considerable. 

Several  large  and  well  arranged  rooms  in  the  college  building  are  used  for  dis- 
pensary work,  one  hour  daily.  The  attendance  is  fair. 
Date  of  visit:  April,  1909. 

General  Considerations 

IN  Nebraska,  as  in  most  of  the  western  states,  the  hope  of  sound  instruction  in 
medicine  lies  with  the  state  university.  There  is  apparently  no  other  institution  in  the 
state  which  can  confidently  count  on  spending  much  more  on  a  medical  department 
than  fees  bring  in,  though  Creighton  has  succeeded  in  obtaining  gifts  for  building 
purposes.  The  problem  confronting  the  state  university,  however,  is  not  simple.  It 
has  undertaken  to  require  two  years  of  college  work  for  entrance,  while  the  state  law 
does  not  contemplate  the  enforcement  of  even  a  high  school  standard.  The  strength- 
ening of  the  law,  by  way  of  backing  the  state  university,  ought  not,  however,  to  be 
difficult,  for  the  eclectic  school  is  surely  without  influence  and  Creighton  has  prom- 
ised to  come  to  the  higher  standard  in  1910. 

A  more  perplexing  problem  arises  from  the  division  of  the  state  university  depart- 
ment between  Omaha  and  Lincoln.  The  edges  of  the  two  halves  do  not  now  touch. 
If  our  position  in  respect  to  divided  schools  is  correct,  the  state  must  choose  between 
wholly  dropping  clinical  instruction  and  organizing  a  complete  school  on  one  of  the 
two  sites  now  partially  occupied.  An  entire  department  at  Omaha  seems  at  this  mo- 
ment the  more  feasible. 

NEW  ENGLAND 

THE  medical  schools  of  Massachusetts,  Maine,  Vermont,  New  Hampshire,  Connecticut 
(nine  in  all),  may  profitably  be  considered  together,  for  the  reputable  ones  among 
them  are  largely  engaged  in  training  local  students,  85  per  cent  of  their  enrolment 


MEDICAL  EDUCATION 


coming  from  this  section.  At  present,  the  ratio  of  physicians  to  population  in  this 
section  is  1 :  592,  not  reckoning  osteopaths.  The  section  is  thus  badly  overcrowded 
with  physicians;  and  as  population  is  increasing  slowly,  there  is  no  possibility  that 
its  increase  will  within  a  generation  bring  about  a  satisfactory  adjustment.  In  the 
matter  of  distribution,  the  usual  conditions  prevail :  cities  and  small  towns  are  alike 
oversupplied.1 

It  is  clear,  then,  that  New  England  will  need  no  more  physicians  for  years  to  come; 
it  can  of  course  begin  none  too  soon  the  process  of  substituting  a  higher  grade  of 
physician  for  what  it  now  has.  To  bring  about  a  gradual  reconstruction  of  the  pro- 
fession, it  is  important  that  certain  legal  changes  be  promptly  made.  Massachusetts, 
for  example,  remains  one  of  three  states  which  obstructs  the  improvement  of  medical 
education  by  permitting  non-graduates  to  be  examined  for  license.  The  law  should 
not  only  require  graduation  from  a  reputable  medical  school,  but  should,  in  the  in- 
terest of  the  public,  fix  with  due  warning  a  minimum  basis  for  admission  thereto,  as 
Connecticut  has  wisely  done,  and  should  empower  and  require  the  state  boards  to 
refuse  examination  to  graduates  of  schools  whose  facilities  are  inadequate.  Of  course, 
a  thorough  practical  examination  would  still  further  increase  the  effectiveness  of  the 
boards  in  protecting  the  public  against  ill  trained  practitioners. 

If,  now,  the  law  prescribed  a  thorough  knowledge  of  physics,  chemistry,  and  biology 
— surely  feasible  in  New  England  if  feasible  in  Minnesota  and  Indiana  — as  the 
minimum  basis  of  medical  education,  attendance  in  medical  schools  would  promptly 
shrink  in  number  and  improve  in  quality.  A  more  critical  attitude  on  the  part  of  the 
state  boards  and  the  student  body  in  reference  to  the  educational  advantages  offered 
by  the  several  schools  would  probably  result  in  a  reconstruction  of  the  situation 
somewhat  along  these  lines : 

A  thoroughly  wretched  institution,  like  the  College  of  Physicians  and  Surgeons 
of  Boston,  would  be  at  once  wiped  out.  The  clinical  departments  of  Dartmouth, 
Bowdoin,  and  the  University  of  Vermont  would  certainly  be  lopped  off;  there  is  no 
good  reason  why  these  institutions — colleges  all  of  them — should  be  concerned  with 
medicine  at  all.  The  mere  fact  that  they  are  all  old  schools  is  a  poor  reason  for  con- 
tinuing them  if  they  fail  to  do  justice  to  the  student,  and  thereby  fail  to  subserve 


1  By  way  of  example,  the 
Massachusetts: 


State  ratio,  1 

svr 

Maine  : 
State  ratio,  1 

000 

New  Hampshire 
State  ratio,  I 

051 

Vermont: 
State  ratio,  I 

534 

Connecticut: 
State  ratio,  1 

740 

Rhode  Island  : 
State  ratio,  I 

724 

following  are  cited  at  random  ; 

Onset 

Westport 

Sacp 

Springfield 

Lisbon  Falls 

Centerville 

Lisbon 

Orford 

Plainfleld 

Newhaven 

Randolph 

Stefhey  Depot 

Suffield 

Centerdale 

Thornton 

Wickford 


population   til  number  of  phytriciang  4 
u  900       "         *          «  3 


C270 

582 

300 

88 

2100 
704 
040 
040 

3000 
420 

3400 
270 
413 

1913 


NEW  HAMPSHIRE  263 

the  public  interest.  They  originated  as  didactic  schools,  and  as  such  were  quite  as  well 
off  in  small  communities  as  anywhere  else.  They  find  themselves  now  compelled  to 
teach  clinical  medicine  by  practical  methods.  They  cannot  command  the  necessary 
material  nor  the  financial  resources  required  to  procure  it.  Why  should  either  the 
students  or  the  public  make  a  sacrifice  merely  to  enable  them  to  continue,  when  it 
is  easily  possible  for  both  to  do  better?  The  argument  that  these  small  schools 
train  all-round  doctors  who  go  out  into  the  country,  prepared  to  do  everything,  is 
refuted  by  the  obvious  fact  that  schools,  unable  to  command  obstetrical  cases,  con- 
tagious diseases,  and  the  ailments  that  throng  dispensaries,  are  not  really  sending 
out  the  type  of  practitioner  which,  by  their  own  admission,  the  rural  districts  need. 
Whether  even  Boston  will  or  should  continue  to  support  two  regular  schools — 
Harvard  and  Tufts — is  decidedly  doubtful.  The  enrolment  of  Tufts,  even  on  the  high 
school  basis,  is  much  swollen.  The  strict  enforcement  of  that  standard — and  why 
should  it  not  be  enforced? — will  greatly  reduce  the  attendance.  The  inevitable  ele- 
vation of  requirements  will  still  further  cut  it  down.  The  school  has  no  resources  but 
fees;  out  of  them  it  cannot  possibly  provide  for  the  legitimate  demands  of  the  near 
future.  It  is  difficult  to  see  how  the  department  in  question  can  avoid  being  seriously 
crippled;  for  its  remarkable  prosperity  has  depended  to  no  slight  extent  on  the  in- 
ducement held  out  by  low  entrance  standards.  Its  only  hope  of  escape  is  through 
endowment,  first,  so  that  it  may  develop  its  laboratories  independently  of  fee  income, 
next,  that  it  may  secure  its  own  hospital.  Why  should  such  an  expensive  step  be 
recommended?  If  New  England  is  in  future  to  be  supplied  with  high-grade  doctors, 
the  quickest  and  cheapest  road  to  that  end  is  to  complete  Harvard  and  to  develop 
Yale,  rather  than  to  maintain  several  more  or  less  imperfect  institutions.  Whatever 
may  once  have  been  the  case,  local  competition  needs  no  longer  be  relied  on  to  ex- 
pose defects  and  to  stimulate  improvement.  Keen  scientific  and  educational  emulation 
over  a  wide  area  provides  a  sharper  incentive  and  involves  no  waste.  It  is,  therefore, 
of  supreme  importance  that  higher  standards  be  legalized  in  New  England  and  that 
the  clinical  independence  of  the  Harvard  Medical  School  be  established.  The  medi- 
cal department  of  Yale  is  modestly  working  in  the  same  spirit  and  to  the  same  end. 
To  these  two  institutions  the  future  of  medical  education  in  New  England  may  for 
many  years  to  come  be  safely  left. 

NEW  HAMPSHIRE 

Population,  443,140.  Number  of  physicians,  680.  Ratio,  1 :  651. 
Number  of  medical  schools,  1. 

HANOVER  :  Population,  1951. 

DARTMOUTH  MEDICAL  SCHOOL.  Organized  1798.  The  medical  department  of  Dart- 
mouth College. 


264  MEDICAL  EDUCATION 

Entrance  requirement :  A  four-year  high  school  education. 
Attendance:  58,  91  per  cent  from  New  England. 

Teaching-  staff ':  24,  of  whom  17  are  professors,  7  of  other  grade.  There  are  two  pro- 
fessors giving  entire  time  to  medical  subjects,  viz.,  pathology,  bacteriology,  and 
physiology.  Chemistry,  botany,  embryology,  and  comparative  anatomy  are  taught 
in  the  regular  college  laboratories.  Ten  clinical  professors  and  one  lecturer  are  non- 
resident. 

Resources  available  for  maintenance:  The  department  is  carried  by  the  general  re- 
sources of  Dartmouth  College.  The  income  in  fees  is  $5583  (estimated). 

Laboratory  facilities :  Excellent  working  laboratories  are  provided  for  pathology, 
bacteriology,  histology,  physiology,  and  for  the  medical  subjects  cared  for  in  the 
academic  department.  Every  student  serves  four  weeks  during  his  second  year  as 
assistant  in  the  pathological  laboratory  and  thus  gets  an  admirable  practical  expe- 
rience. Anatomy,  taught  by  a  practitioner,  has  not  as  yet  been  developed  on  mod- 
ern lines.  There  are  good  departmental  libraries,  supplied  with  books  and  current 
periodicals,  foreign  and  domestic. 

Clinical  facilities:  These  are  very  limited.  The  college  controls  a  hospital  of  40  beds, 
of  which  24  are  in  wards  at  reduced  rates.  These  are  available  for  teaching ;  to  some 
extent  private  cases  may  also  be  demonstratively  used.  Still  further  to  weaken  the 
teaching  value  of  the  hospital,  surgery  predominates  to  the  extent  of  80  per  cent 
of  all  cases.  Students  are  employed  to  assist  in  surgical  operations,  but  the  back- 
bone of  clinical  instruction — an  adequate  clinic  in  internal  medicine — is  lacking. 
An  isolation  pavilion  of  fourteen  beds  for  college  use  is  employed  for  teaching 
as  occasion  presents.  For  obstetrical  work,  students  sojourn  for  a  period  in  Boston 
or  New  York.  There  are  12—14  post-mortems  a  year. 

There  is  no  dispensary. 
Date  ofvuit :  March,  1910. 

General  Considerations 

DARTMOUTH  is  already  providing  excellent  modern  instruction  in  most  of  the  work 
of  the  first  two  years.  The  development  of  its  clinical  work  presents  a  serious  diffi- 
culty. The  village  is  rather  inaccessible;  the  surrounding  country  is  thinly  populated, 
— containing  perhaps  50,000  people  in  a  zone  100  miles  north  and  south.  Surgical 
cases  are  attracted  easily  enough.  Can  medical  cases  be  attracted  too?  Certainly  not 
without  a  very  large  outlay  in  the  form  of  professional  salaries  and  hospital  expense. 
To  what  extent  a  compulsory  fifth  year  spent  as  interne  in  a  large  hospital  would 
answer  in  compensation  of  defective  facilities  is  a  question:  much  depends  on  the 
hospitals  available  for  the  purpose.  That  the  school  cannot  much  longer  continue 
in  its  present  stage  is  clear:  for  with  the  requirement  of  two  years  of  college  work 


NEW  YORK  265 

for  entrance  in  1910,  it  asks  a  student  to  spend  six  years  to  get  a  degree  in  medicine, 
in  attaining  which  he  can  enjoy  only  a  very  limited  opportunity  to  learn  internal 
medicine.  It  is  safe  to  predict  that  on  that  basis  the  present  facilities  will  not  hold 
the  student  body  together  during  the  third  and  fourth  years. 
[See  "New  England," p.  261.] 

NEW  YORK 

Population,  8,706,039.  Number  of  physicians,  14,117.  Ratio,  1:  617. 
Number  of  medical  schools,  11,  plus  4  postgraduate  schools. 

ALBANY:  Population,  101,461. 

(1)  ALBANY  MEDICAL  COLLEGE.  Organized  1838.  Nominally  the  medical  department 
of  Union  University;  actually  an  independent  institution  in  all  but  form. 

Entrance  requirement:  The  Regents'  Medical  Student  Certificate. 
Attendance:  180,  91  per  cent  from  New  York  state. 

Teaching  staff:  94,  of  whom  16  are  professors,  78  of  other  grade.  The  professor  of 
chemistry,  the  associate  professor  of  physiology,  and  the  director  of  the  Bender 
Laboratory  are  non-practitioners. 

Resources  available  for  maintenance:  Practically  fees  only,  amounting  to  $20,276. 
$10,000  have  been  bequeathed  to  the  school  as  the  nucleus  of  a  building  fund. 

Laboratory  facilities :  The  Bender  Laboratory,  at  a  considerable  distance  from  the 
school, — with  endowment  sufficient  to  keep  up  insurance  and  repairs, — provides 
instruction  in  pathology,  bacteriology,  histology  (not  including  embryology),  clini- 
cal microscopy,  and  a  small  amount  of  demonstrative  work  in  physiology.  There 
is  no  course  in  pharmacology.  The  head  of  the  laboratory  is  pathologist  to  the 
Albany  Hospital  and  other  institutions;  autopsies  are  thus  procured.  The  labora- 
tory has  made  itself  practically  self-supporting  through  board  of  health  and  simi- 
lar work.  The  college,  after  equipping  it,  now  contributes  to  its  support  no  more 
than  it  absolutely  must  in  order  to  keep  it  going.  In  consequence,  there  is  now 
little  active  research  in  progress. 

At  the  medical  school  building  good  laboratories  are  provided  for  chemistry 
and  physiological  chemistry,  and  the  usual  dissecting-room  with  a  few  charts, 
models,  etc.  Otherwise  equipment  is  scant.  The  laboratory  branches  have  been 
slighted  in  pursuance  of  the  policy  of  paying  annual  dividends  to  the  faculty. 

Clinical  facilities:  The  main  clinical  reliance  is  the  Albany  Hospital,  in  which  per- 
haps 200  beds  are  available.  But  three-fourths  of  the  work  of  the  hospital  is  sur- 
gery. The  service  in  medicine  and  surgery  rotates  every  three  months.  On  the 
medical  side,  students  work  up  assigned  cases.  In  general  surgery,  students  can  only 


266  MEDICAL  EDUCATION 

"look  on."  They  have  no  access  to  the  obstetrical  ward,  though  students  serving 
as  externes  are  allowed  to  observe  free  cases.  Other  institutions  furnish  supple- 
mentary material  in  obstetrics,  pediatrics,  mental  diseases,  etc. 

The  school  uses  two  dispensaries:  that  at  the  hospital  is  unimportant;  the  South 
End  Dispensary  has  a  fair  attendance  and  is  conducted  in  an  orderly  manner. 
Date  of  vitit :  January,  1910. 

BROOKLYN:  Population,  1,543,630. 

(2)  LONG  ISLAND  COLLEGE  HOSPITAL.  Organized  1858.  An  independent  institution. 

Entrance  requirement :  The  Regents'*  Medical  Student  Certificate. 

Attendance:  360,  89  per  cent  from  New  York  state. 

Teaching-  staff':  94,  9  being  professors,  85  of  other  grade.  There  is  no  full-time 
instructor  belonging  to  the  school. 

Resources  available  for  maintenance:  Fees,  amounting  to  $61,398.  Practically  this 
amount  is  supplemented  by  advantageous  arrangements  to  be  described  below  in 
connection  with  laboratory  and  clinical  facilities. 

Laboratory  facilities:  The  Hoagland  Laboratory  (endowment  $131,000),  independent 
of  but  affiliated  with  this  school,  sets  aside  a  suite  of  rooms,  in  which  pathology, 
bacteriology,  and  histology  are  taught  to  medical  students.  The  college  is  thus 
partly  relieved  of  the  expense  involved  in  the  equipment  and  teaching  of  these 
branches.  The  opportunities  provided  are  of  routine  character.  The  research  work 
of  the  laboratory  and  its  teaching  are  entirely  distinct. 

The  college  itself  contains  a  good  and  well  kept  dissecting-room,  in  which  draw- 
ing and  modeling  are  employed,  and  two  good,  though  ordinary,  chemical  lab- 
oratories. 

There  is  no  library,  no  museum,  no  physiological  or  pharmacological  labora- 
tory, though  a  demonstration  course  in  physiology  is  offered.  Freed  from  the  ne- 
cessity of  providing  certain  laboratories,  fees  might  have  been  used  to  provide 
others;  instead  of  that,  the  surplus  is  annually  divided  among  the  faculty.  What 
gifts  have  not  provided,  the  college  goes  on  lacking. 

Clinical  facilities:  The  school  adjoins,  and  is  legally  one  with,  the  Long  Island  Col- 
lege Hospital,  with  200  beds  usable  in  teaching.  The  hospital,  though  new,  is  not 
designed  to  serve  modern  ideas  in  medical  teaching.  It  lacks  adequate  laboratories; 
specimens  must  be  carried  by  students  to  the  college  building  for  examination. 

For  dispensary  purposes,  the  college  gets  the  use  of  the  Polhemus  Clinic,  built 
at  a  cost  of  $500,000,  having  a  productive  endowment  of  $400,000. 

The  entire  plant — school  and  clinic — is  admirably  kept. 

Dot*  of  vitit :  March,  1909. 


NEW  YORK  267 

BUFFALO :  Population,  401,441. 

(3)  UNIVERSITY  OF  BUFFALO  MEDICAL  DEPARTMENT.  Organized  1846.  Despite  the  uni- 
versity charter,  the  University  of  Buffalo  is  a  fiction.  Schools  of  medicine,  law, 
dentistry,  and  pharmacy  are  aggregated  under  the  designation ;  but  they  are  to  all 
intents  and  purposes  independent  schools,  each  living  on  its  own  fees. 

Entrance  requirement:  Admission  is  on  the  basis  of  the  Regents'  Medical  Student 
Certificate,  being  the  equivalent  of  a  high  school  education. 

Attendance:  193. 

Teaching  staff:  97,  of  whom  38  are  professors. 

Resources  available  for  maintenance:  Fees  amounting  to  $31,984. 

Laboratory  facilities :  The  school  has  a  conventionally  adequate  equipment  for  an- 
atomy, ordinary  laboratories  for  chemistry,  bacteriology,  and  pathology,  a  meager 
outfit  in  physiology, — it  having  been  found  that  the  students  cannot  profitably  do 
much  experimental  work  themselves, — nothing  for  pharmacology.  The  "whole- 
time"  teachers  have  in  the  main  other  duties  besides  teaching  in  medicine:  the 
professor  of  pathology  and  bacteriology  is  registrar,  the  chemist  officiates  in  the 
pharmacy  department,  the  anatomist  in  the  dental  department.  There  is  a  small 
museum,  but  a  good  library  of  8000  volumes,  current  German  and  English  periodi- 
cals, with  a  librarian  in  charge. 

Clinical  facilities :  For  clinical  teaching,  the  school  relies  mainly  on  the  Buffalo  Gen- 
eral Hospital  close  by.  It  has  access  to  some  200  beds,  used  for  demonstrative 
teaching  in  the  wards.  Records  are  made  by  internes.  Students  do  no  clinical  labo- 
ratory work  in  connection  with  special  patients,  the  teaching  in  clinical  micro- 
scopy being  separately  given  at  the  college.  Infectious  diseases  are  didactically 
taught.  Clinical  obstetrics  is  imperfectly  organized.  Besides  the  Buffalo  General 
Hospital,  a  weekly  clinic  is  held  at  the  County  Hospital,  four  miles  distant,  four 
clinics  at  the  Sisters'  Hospital,  one  and  a  half  miles  away,  etc. 

Despite  the  size  of  the  city,  the  college  dispensary  is  wretched.  It  has  an  at- 
tendance of  perhaps  3000  during  the  college  year,  skin,  eye,  and  ear  cases  mainly. 
A  definite  statement  is  impossible  because  there  are  no  systematic  records.  The 
rooms  are  ill  equipped.  Records  consist  of  brief  pencil  notes  in  separate  books, 
usually  without  index.  The  work  is  hastily  and  superficially  done,  and  its  influ- 
ence on  the  students,  so  far  as  it  goes,  must  be  thoroughly  bad.  The  catalogue 
states,  however,  that  as  attendance  in  the  dispensary  is  obligatory,  each  student 
"will  secure  an  unusually  thorough  training  in  the  taking  and  recording  of  his- 
tories." 

Date  of  visit:  October,  1909. 


268  MEDICAL  EDUCATION 

NEW  YORK:  Population,  4,563,604. 

(4)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  The  Medical  Department  of  Columbia 
University.  Organized  in  1807;  affiliated  with  Columbia  College  1860;  an  organic 
part  of  Columbia  University  since  1891. 

Entrance  requirement:  The  Regents'*  Medical  Student  Certificate,  which  must  in- 
clude physics  and  chemistry.  Of  the  present  first-year  class  of  86,  48  have  the 
bachelor's  degree,  11  more  have  had  at  least  two  years  of  college  work:  the  de- 
partment is  therefore  already  close  to  the  two-year  college  basis,  which  goes  into 
effect  1910-11. 

Attendance:  312,  56  per  cent  from  New  York  state. 

Teaching  staff:  176,  of  whom  38  are  professors,  138  of  other  grade. 

Resources  available  for  maintenance:  The  department  has  special  endowments  amount- 
ing to  $832,351.  Fees  amount  to  $75,500.  The  budget  calls  for  $239,072,  includ- 
ing maintenance  of  Sloane  Maternity  Hospital  and  the  Vanderbilt  Clinic. 

Laboratory  facilities:  The  school  laboratories  are  of  modern  equipment  and  organ- 
ization, conducted  by  full-time  instructors,  amply  assisted.  Teaching  and  research 
are  thus  actively  prosecuted  in  all  departments.  Anatomy  deserves  to  be  especially 
mentioned,  as  perhaps  the  most  elaborate  plant  of  its  kind  in  the  country.  The 
school  lacks  a  general  library,  though  books  and  periodicals  are  available  in  sev- 
eral departments  and  in  the  students'  study. 

Clinical  facilities :  The  school  is  admirably  situated  in  i-espect  to  the  Sloane  Maternity 
Hospital  (to  which  gynecology  is  now  to  be  added)  and  the  Vanderbilt  Clinic  (dis- 
pensary), which  adjoin  it  and  are  under  its  control.  Both  philanthropically  and 
pedagogically,  they  are  effectively  conducted  on  modern  lines. 

In  other  respects,  the  clinical  department  labors  under  the  disadvantages  com- 
mon to  the  schools  of  New  York.  The  situation  will  be  more  fully  discussed  be- 
low; suffice  it  here  to  say  that  various  hospitals  furnish  an  abundance  of  clinical 
material  of  all  kinds  under  limitations  that  interfere  with  effective  scientific  or 
pedagogic  use,  and  make  exceedingly  difficult  anything  like  intimate  interplay 
between  laboratory  and  clinical  teaching.  Nowhere  has  the  school  rights;  at 
Bellevue  (municipal  hospital),  custom  establishes  a  qualified  security,  liable,  how- 
ever, to  be  disregarded;  elsewhere  the  basis  is  purely  personal.  Permission  has  re- 
cently been  obtained  to  institute  clinical  clerking  in  a  few  places. 

Date  of  rntit:  October,  1909. 

(5)  CORNELL  UNIVERSITY  MEDICAL  COLLEGE.  Organized  1898.  An  organic  department 
of  Cornell  University. 

Entrance  requirement:  Three  years  of  college  work. 


NEW  YORK 

Attendance:  207. 

Teaching  staff:  132,  32  being  professors,  100  of  other  grade. 

Resources  available  for  maintenance:  The  department  is  liberally  supported.  Its 
budget  (New  York  city)  calls  for  $209,888;  income  from  fees,  $24,410;  Ithaca: 
budget,  $32,840;  income  from  fees  is  negligible. 

Laboratory  facilities :  The  school  laboratories  in  New  York  are,  in  general,  of  modern 
equipment  and  organization,  anatomy  and  chemistry  being,  however,  less  elabo- 
rately developed  than  physiology  and  pathology.  The  professor  of  anatomy  is  a 
practising  surgeon.  Otherwise  the  laboratories  are  in  charge  of  full-time  teachers, 
properly  assisted,  devoting  themselves  unreservedly  to  teaching  and  research.  De- 
spite geographical  separation  from  the  university  at  Ithaca,  the  department  is 
animated  by  university  ideals:  in  part,  this  is  ascribable  to  actual  intercourse,  in 
part,  to  the  selection  of  teachers  devoted  to  science,  whom  the  university  has  so  gen- 
erously supported  that  they  have  reproduced  the  university  spirit.  At  Ithaca — the 
seat  of  Cornell  University — the  first  year's  instruction  is  also  offered:  the  depart- 
ments of  anatomy  and  physiology  as  there  organized  and  conducted  are  thoroughly 
admirable,  with  their  own  additional  teaching  staff,  supported  by  separate  funds. 

Clinical  facilities:  The  major  part  of  the  clinical  instruction  is  given  at  the  Bellevue 
Hospital,  directly  opposite  the  college,  in  which  the  school  enjoys  the  same  privi- 
leges as  Columbia  and  New  York  Universities.  The  service  is  good  in  point  of 
extent;  limitations  which  render  it  unsatisfactory  will  be  discussed  below.  Sup- 
plementary hospitals  increase  the  amount  of  available  material,  but  always  under 
serious  pedagogic  restrictions.  Intimate  correlation  of  laboratories  and  clinic  is 
thus  not  feasible. 

A  thoroughly  satisfactory  dispensary,  well  conducted,  occupies  part  of  the  school 
building. 

Date  of  visit:  February,  1910. 

(6)  UNIVERSITY  AND  BELLEVUE  HOSPITAL  MEDICAL  COLLEGE.  Formed  in  1898  by 
merger  of  University  Medical  College  (established  1841)  and  Bellevue  Hospital 
Medical  College  (established  1861).  An  integral  part  of  New  York  University. 

Entrance  requirement:  The  Regents'  Medical  Student  Certificate,  representing  a  four- 
year  high  school  education. 

Attendance:  408,  74  per  cent  from  New  York  state. 
Teaching  staff:  164,  37  being  professors,  127  of  other  grade. 

Resources  available  for  maintenance:  The  school  is  mainly  dependent  on  fees,  amount- 
ing to  $76,115;  these  are  supplemented  by  gifts  and  income  from  endowment 
amounting  to  about  $11,000. 


270  MEDICAL  EDUCATION 

Laboratory  facilities:  The  laboratories  are  developed  unevenly,  as  the  resources  of 
the  school  are  not  equal  to  uniform  promotion  of  all  the  medical  sciences.  Patho- 
logy is  excellently  organized  and  equipped  both  for  teaching  and  research;  in  other 
branches  good  teaching  facilities  rather  than  any  considerable  opportunity  for  in- 
vestigation have  been  aimed  at.  The  departments  of  pathology,  physiology,  phar- 
macology, and  chemistry  are  in  charge  of  full-time  teachers.  Anatomy,  including 
histology  and  embryology,  has  just  been  reorganized  on  the  same  basis.  Available 
laboratory  accommodations  are  being  largely  increased  by  an  addition  now  in  pro- 
cess of  erection. 

Clinical  facilities :  The  major  part  of  the  clinical  instruction  is  given  at  Bellevue 
Hospital,  opposite  the  college,  in  which  the  school  enjoys  the  same  privileges  as 
Cornell  and  Columbia.  The  service  is  good  in  point  of  extent.  Limitations  which 
make  it  unsatisfactory  will  be  discussed  below.  Supplementary  hospitals  increase 
the  amount  of  available  material,  but  always  under  serious  pedagogic  restric- 
tions. Intimate  correlation  of  laboratories  and  clinic  within  the  hospital  is  thus 
not  feasible. 

A  thoroughly  satisfactory  dispensary,  well  conducted,  occupies  part  of  the 
school  building. 

Date  of  visit :  November,  1909. 

(7)  FORDHAM  UNIVERSITY  SCHOOL  OF  MEDICINE.  Organized  1905.  An  organic  part  of 
Fordham  University. 

Entrance  requirement:  Something  over  a  four-year  high  school  education. 
Attendance:  42,  83  per  cent  from  New  York  state. 

Teaching  staff":  72,  of  whom  32  are  professors,  40  of  other  grade.  Two  instructors 
give  their  entire  time  to  the  medical  school.  Chemistry  and  physiology  are  taught 
in  the  university  by  full-time  teachers. 

Resources  available  for  maintenance:  Fees,  amounting  to  $7330  (estimated  1908-9), 
supplemented  by  appropriations  amounting  to  several  thousand  dollars  annually 
from  the  general  funds  of  the  university. 

Laboratory  facilities :  Chemistry  and  physiology  are  explained  above.  The  equipment 
in  pathology,  bacteriology,  and  histology  is  adequate  for  the  routine  instruction 
of  the  small  student  body.  Anatomy  is  limited  to  dissection.  There  is  a  library 
with  current  scientific  journals. 

Clinical  facilities :  Much  of  the  clinical  work  of  the  school  is  carried  on  at  Fordham 
Hospital,  a  municipal  institution  close  by;  the  school  has  no  voice  in  making  its 
staff  appointments.  Supplementary  opportunities  are  obtained  at  other  institu- 
tions,— scattered,  as  is  generally  the  case,  with  the  medical  schools  of  the  city.  The 
amount  of  material  available  is  adequate,  but  it  cannot  be  organized  or  controlled. 


NEW  YORK  271 

There  is  a  good  and  growing  dispensary  service  connected  with  Fordham  Hospital. 
Date  of  visit:  October,  1909. 

(8)  NEW  YORK  MEDICAL  COLLEGE  AND  HOSPITAL  FOE  WOMEN.  Homeopathic.  Organ- 
ized 1863.  An  independent  school. 

Entrance  requirement:  Regents'  Medical  Student  Certificate,  equivalent  to  a  four- 
year  high  school  course. 

Attendance:  24. 

Teaching  staff:  45,  23  being  professors,  22  of  other  grade.  No  teacher  devotes  entire 
time  to  the  school. 

Resources  available  for  maintenance:  Fees,  amounting  to  $2545. 

Laboratory  facilities:  Attractive  and  well  kept  laboratories  are  provided  for  patho- 
logy, bacteriology,  and  histology  together,  chemistry  and  physiology  and  anatomy. 
The  equipment  is  simple,  but  recent.  There  are  a  small  library,  a  number  of  ana- 
tomical charts,  and  some  normal  and  pathological  preparations.  Autopsy  material 
is  reported  as  scarce. 

Clinical  facilities :  These  consist  of  the  hospital,  occupying  the  same  building  and 
containing  35  available  beds,  most  of  the  cases  being  surgical,  and  of  the  usual 
rotating  services  scattered  among  other  hospitals,  public  and  private.  They  do  not 
include  infectious  diseases. 

Most  of  the  first  floor  of  the  school  building  is  given  over  to  a  dispensary. 

Date  of  visit:  October,  1909. 

(9)  ECLECTIC  MEDICAL  COLLEGE.  Organized  1865.  An  independent  school. 
Entrance  requirement:  Regents'  Medical  Student  Certificate. 
Attendance:  96,  84  per  cent  from  New  York  state. 

Teaching  staff:  45,  16  being  professors,  29  of  other  grade.  No  one  devotes  full  time 
to  teaching. 

Resources  available  for  maintenance:  Mainly  fees,  amounting  to  $8311. 

Laboratory  facilities :  The  chemical  laboratory,  adequate  for  routine  teaching,  is  ac- 
tive. Otherwise  the  facilities  are  weak :  one  room  is  used  for  bacteriology,  histology, 
pathology,  and  clinical  microscopy;  this  with  the  dissecting-room  completes  the 
laboratory  outfit.  There  is  no  museum ;  but  the  school  possesses  a  small  collection 
of  models,  a  materia  medica  cabinet,  a  stereopticon,  and  a  fair-sized  library,  of 
which  the  books  are  mostly  not  recent. 

Clinical  facilities :  There  is  no  eclectic  hospital.  Twice  weekly  three  students  spend 
their  entire  afternoon  at  the  Sydenham  Hospital  (80  free  beds).  There  are  some 


272  MEDICAL  EDUCATION 

supplementary  clinics  of  the  usual  kind.  There  is  a  small  dispensary  in  the  school 
building  and  an  outside  dispensary  is  also  used.  The  clinical  facilities  are  utterly 
inadequate  in  respect  to  both  extent  and  control. 
Dato  ofvitit:  March,  1909. 

(10)  NEW  YORK  HOMEOPATHIC  MEDICAL  COLLEGE  AND  FLOWER  HOSPITAL.  Organized 
1858.  An  independent  institution. 

Entrance  requirement:  Regents'  Medical  Student  Certificate. 
Attendance:  159,  88  per  cent  from  New  York. 

Teaching  staff:  65,  of  whom  31  are  professors,  34  of  other  grade.  The  professors  of 
chemistry,  physiology,  pathology,  and  bacteriology  are  full-time  teachers. 

Resources  available  for  maintenance:  The  school  and  hospital  budgets  are  combined. 
The  institution  has  an  endowment  of  $600,000,  which  carries  a  hospital  of  125 
free  beds,  dispensary  with  ambulance  service,  etc.  Income  from  student  fees 
amounts  to  $18,658. 

Laboratory  facilities :  An  attractive,  well  kept  laboratory  with  models  and  bone- 
mounts  is  provided  for  anatomy;  a  single  laboratory  for  chemistry;  one,  with  a 
small  museum,  for  pathology  and  histology ;  and  others,  with  ordinary  equipment, 
for  bacteriology  and  physiology.  There  is  a  library  of  several  thousand  volumes. 

Clinical  facilities:  Though  the  school  possesses  its  own  hospital,  clinical  teaching  has 
not  hitherto  been  so  organized  as  to  take  the  fullest  advantage  of  it.  The  records 
are  meager;  the  clinical  laboratory  inadequate.  Improvements  are,  however,  under 
way. 

The  dispensary  enjoys  a  very  large  attendance. 

Date  ofvint:  December,  1909. 

SYRACUSE:  Population,  127,281. 

(11)  COLLEGE  OF  MEDICINE,  SYRACUSE  UNIVERSITY.  Organized  1872.  An  integral  de- 
partment of  the  university. 

Entrance  requirement:  A  year's  work  in  science  in  addition  to  the  Regents'  Medical 
Student  Certificate.  Credentials  are  passed  upon  by  the  academic  authorities.  Of 
the  present  class  of  40,  the  first  on  the  new  basis,  20  had  had  a  year  or  more 
of  college  work ;  the  rest  presented  high  school  or  preparatory  school  certificates 
in  the  required  sciences. 

Attendance:  151,  90  per  cent  from  New  York  state. 

Teaching-  staff':  57,  of  whom  1 5  are  professors  and  42  of  other  grade.  The  sciences 
are  taught  by  full-time  teachers. 


NEW  YORK  278 

Resources  available  for  maintenance:  Income,  almost  wholly  from  fees,  amounting  to 
$28,861. 

Laboratory  facilities:  Chemistry  is  well  cared  for  in  the  university  laboratories.  The 
equipment  in  anatomy,  physiology,  pathology,  including  clinical  microscopy  and 
bacteriology,  is  adequate  for  instruction ;  the  income  of  the  school  has  been  con- 
sistently and  intelligently  used  to  develop  these  departments.  They  are  all  in 
charge  of  full-time  teachers,  each  provided  with  a  competent  helper.  There  is  a 
good  library,  in  charge  of  a  librarian,  but  no  museum. 

Clinical  facilities :  Clinical  facilities  have  not  yet  been  put  on  the  same  modern  basis 
as  the  laboratory  branches.  They  are  insufficient  in  respect  to  both  extent  and  con- 
trol. The  school  relies  mainly  on  two  local  hospitals  of  about  150  beds,  providing 
ward  and  bedside  work  in  general  medicine,  surgery,  and  pediatrics,  surgery  pre- 
dominating. The  hospitals  do  not  contain  a  working  clinical  laboratory  for  stu- 
dents. Supplementary  opportunities  are  provided  by  several  other  institutions  in 
the  usual  manner.  The  work  in  obstetrics  is  not  sufficient. 

Students  attend  the  city  dispensary,  which  is,  from  an  educational  point  of  view, 
of  doubtful  value.  It  has  an  attendance  of  10,000;  but  the  records,  though  sys- 
tematic, are  so  brief  that  the  experience  would  hardly  conduce  to  thorough  and 
careful  habits.  The  head  clinical  professors  have  apparently  been  indifferent  to  it. 

Date  of  visit:  October,  1909. 

POSTGRADUATE  SCHOOLS 

(1)  BROOKLYN  POSTGRADUATE  MEDICAL  SCHOOL.  Established  1907. 
Entrance  requirement:  The  M.D.  degree. 

Attendance:  Students  are  scarce;  four  or  five  may  be  in  attendance  at  any  one  time. 
Teaching  staff":  52,  of  whom  19  are  professors,  33  of  other  grade. 
Resources  available  for  maintenance:  Fees. 
Laboratory  facilities :  None. 

Clinical  facilities:  The  school  offers  graduate  courses  mainly  in  the  Williamsburg  Hos- 
pital, most  of  the  cases  in  which  are  surgical.  The  hospital  itself  is  wretched  and  has 
no  teaching  facilities  worth  mentioning.  It  is  even  without  a  clinical  laboratory. 

The  existence  of  the  school  is  a  reproach  to  the  state.  It  now  operates  on  a  limited 
charter  from  the  state  department  of  education,  and  is  enabled  to  continue  because 
it  is  aided  by  the  city.  It  deserved  no  charter  in  the  first  place,  and  it  deserves  no 
recognition  from  the  city  now. 

Date  of  visit:  January,  1910. 

(2)  NEW  YORK  POSTGRADUATE  SCHOOL.  Established  1881. 


274  MEDICAL  EDUCATION 

Entrance  requirement:  The  M.D.  degree. 

Attendance:  There  is  an  average  attendance  of  90  students  in  winter,  50  in  summer. 
Short  courses,  usually  six  weeks  in  length  and  of  a  practical  nature,  are  given. 
Formerly,  the  so-called  "general"  ticket  was  most  popular;  now,  specialties  are  in 
demand  and  the  medical  courses  are  gaining  on  the  surgical. 

Teaching  staff:  156,  of  whom  38  are  professors,  118  of  other  grade. 

Resources  available  for  maintenance:  The  school,  long  without  productive  resources, 
has  recently  received  a  gift  of  $1,600,000,  which,  after  paying  debts  and  provid- 
ing needed  extensions,  will  leave  a  productive  endowment  of  perhaps  $400,000. 

Laboratory  facilities :  These  are  very  meager.  A  single  room  is  devoted  to  laboratory 
work;  little  or  no  research  or  experimental  work  is  carried  on. 

Clinical  facilities:  The  Postgraduate  Hospital  is  of  modern  construction  and  is  ex- 
cellently conducted.  It  contains  225  beds,  75  per  cent  of  which  are  free.  The  new 
building  will  add  170  beds  and  space  for  clinical  and  laboratory  teaching.  Other 
hospitals  are  also  used. 

There  is  a  good  dispensary,  very  largely  attended. 

Date  ofvitit:  January,  1910. 

(3)  NEW  YORK  POLYCLINIC  MEDICAL  SCHOOL  AND  HOSPITAL.  Organized  1881. 
Entrance  requirement:  The  M.D.  degree. 

Attendance:  25  to  50  students  are  in  attendance  usually. 

Teaching  staff:  149,  of  whom  24  are  professors,  125  of  other  grade. 

Resources  available  for  maintenance:  Fees. 

Laboratory  facilities:  There  is  a  pathological  laboratory  for  practical  work. 

Clinical  facilities:  Postgraduate  instruction  is  offered  in  the  Polyclinic  Hospital  (100 
beds),  in  the  dispensary,  which  is  largely  attended,  and  in  a  considerable  number 
of  other  hospitals,  with  which  members  of  the  faculty  are  connected  as  staff 
officers.  The  instruction  is  practical  in  character. 

Date  ofviiit:  December,  1909. 

(4)  MANHATTAN  EYE,  EAR,  AND  THROAT  HOSPITAL  POSTGRADUATE'  SCHOOL.  Estab- 
lished 1869.  An  independent  institution. 

Entrance  requirement:  The  M.D.  degree. 

Attendance:  There  is  an  average  attendance  of  12  students.  Courses  range  from  one 
to  six  months  or  more  in  length.  Students  who  attend  at  least  three  months  are 
eligible  to  appointment  as  clinical  assistants. 

Teaching  staff:  11. 


NEW  YORK  275 

Resources  available  for  maintenance:  Fees  and  income  from  endowment  of  SI  70,000, 
the  latter  yielding  income  sufficient  to  carry  mortgage. 

Laboratory  facilities:  These  consist  of  two  laboratories,  one  for  pathological,  the 
other  for  bacteriological,  examinations. 

Clinical  facilities :  There  is  an  excellent  modern  hospital,  with  125  ward  beds.  The 
teaching  is  demonstrative  and  practical  in  character,  though  assistants  enjoy 
larger  opportunities. 

The  dispensary  has  a  very  large  daily  attendance. 
Date  of  visit :  April,  1910. 

General  Considerations 

NEW  YORK  has  a  double  duty  and  a  double  opportunity  in  medical  education.  It 
must  in  the  first  place  produce  most  of  its  own  physicians  and  a  considerable  share 
of  those  who  practise  in  neighboring  states,  which,  like  New  Jersey,  are  without 
medical  schools.  Its  eleven  medical  schools  have  so  energetically  done  their  part  in 
this  matter  that  New  York  itself  and  all  the  adjoining  states  are  suffering  from 
plethora.1  There  is,  therefore,  no  section  of  the  Union  which  is  at  this  moment  readier 
for  an  upward  step :  population  is  comparatively  well  distributed,  communication  is 
easy,  roads  are  good,  educational  facilities  abundant,  and  doctors  superabundant. 
In  the  city  of  New  York  the  two-year  college  requirement  can  be  met  at  Columbia, 
New  York  University,  and  without  expense  at  the  College  of  the  City  of  New  York. 
Students  outside  the  metropolis  are,  up  to  a  certain  number,  similarly  cared  for  by 
Cornell  University. 

But  New  York  may  be  fairly  asked  to  do  more  than  produce  doctors,  however 
excellent  the  type.  Its  vast  hospital  and  university  resources  should  make  it  the  Ber- 
lin or  Vienna  of  the  continent;  a  genuinely  productive  contributor  to  medical  pro- 
gress ;  the  center  to  which,  in  the  intervals  of  a  busy  life,  physicians  will  repair  to 
freshen  their  knowledge  and  to  renew  their  professional  youth;  to  which  the  young 
graduate  from  the  interior — from  the  schools  of  Pittsburgh,  Ann  Arbor,  Madison, 
Iowa  City — will  look  for  the  extension  of  his  scientific  and  clinical  experience. 

Little  has  as  yet  been  done  to  realize  this  opportunity.  The  postgraduate  schools 
are  of  very  limited  scope;  the  great  New  York  schools  have  been  in  the  main  clinically 
unproductive.  Why? 

The  reason  is  a  matter  of  history.  The  schools  that  are  now  called  university  de- 
partments grew  up  as  proprietary  institutions.  They  have  never  been  adequately 
financed.  They  obtained,  and  still  obtain,  their  clinical  facilities  at  each  other's  ex- 
pense: that  is  to  say,  what  one  gets,  the  other  loses.  In  the  Bellevue  Hospital  a 
modus  vivendi  was  found  by  division,  with  an  arrangement  that  enables  two  schools 
to  watch  and  obstruct  the  third  and  a  lay  board  to  oversee  all  three;  in  the  great 

!The  ratios  prove  this :  New  York,  1:617;  New  Jersey,  1 :  950 ;  Delaware,  1  :  906 ;  Connecticut,  1 :  740 ; 
Rhode  Island,  1 :  724;  Vermont,  1 :  534. 


276  MEDICAL  EDUCATION 

private  hospitals  personal  considerations  nominate  the  staff,  and  the  school  subse- 
quently negotiates  with  the  appointees.  Competition,  professional  and  institutional, 
has  molded  the  hospital  situation,  and  in  consequence  clinical  faculties  are  organ- 
ized on  a  personal  rather  than  a  scientific  or  educational  basis.  Doubtless  if  Colum- 
bia, New  York  University,  and  Cornell  had  at  this  moment  a  free  hand,  they  would 
retain  some  of  their  clinical  teachers  in  their  present  positions.  But  at  bottom  this  is 
a  fortunate  accident  rather  than  a  natural  result:  it  just  happens  that  some  compe- 
tent teachers  find  themselves  in  prominent  hospital  positions;  but  the  system  is  not 
designed  to  pick  them  out.  In  the  event  of  their  withdrawal,  their  successors  in  the 
hospital  would  not  be  sought  on  the  basis  of  scientific  eminence,  and  if  not  in  the 
hospital,  then  not  in  the  school.  Under  these  conditions,  the  schools  can  hardly  be  said 
to  have  ideals,  policy,  or  genuinely  organized  departments,  except  by  fortunate  acci- 
dent. For  the  nonce,  there  may  be  a  continuous  medical  service  here,  clinical  clerks 
there,  post-mortems  elsewhere.  But  the  favoring  conditions  are  perishable.  The  schools 
skate  on  thin  ice.  An  accident  may  shatter  the  arrangement  and  convert  a  "depart- 
ment" into  a  congeries  of  courses  lacking  unity  in  conduct  and  aim.  Indeed,  most  of 
the  clinical  departments  now  conform  to  just  this  description:  there  are  a  half-dozen 
professors  of  medicine  and  surgery  in  place  of  one;  and  no  possibility  of  team-work 
on  their  part. 

For  many  years  nothing  more  than  this  was  asked ;  but  meanwhile  the  school  point 
of  view  has  changed.  Doubtless  there  are  professors  who  are  satisfied  to  go  on  pro- 
ducing doctors  and  to  let  other  institutions  produce  knowledge;  but  the  produc- 
tivity of  the  first  and  second  years  has  suggested  another  ideal.  The  problems  of 
clinical  medicine  have  been  the  more  sharply  formulated  as  the  pathologist  and  the 
bacteriologist  have  passed  up  to  the  clinician  the  results  of  their  own  scientific  activity. 
The  teachers  of  medicine  must  attack  these  problems.  To  attack  them,  they  require 
quite  another  environment.  The  modus  vivendi  which  enabled  rival  schools  to  lecture  in 
the  same  hospitals  does  not  provide  the  conditions  in  which  a  clinical  scientist  can  work. 

We  have  now  suggested  two  results  that  medical  schools  in  New  York  must  at- 
tain: (1)  they  must  make  doctors  in  sufficient  number;  (2)  they  must  actively  par- 
ticipate in  the  advance  of  medical  science.  If  the  standpoint  previously  expounded 
is  correct,  the  same  institutions  must  do  both.  Of  the  eleven  medical  schools  now 
existing  in  the  state,  only  the  bona-fide  university  departments  can  then  expect  to 
survive:  outside  of  New  York  city,  Syracuse  University  alone  has  just  now  a  chance. 
The  schools  of  Buffalo,  Albany,  and  Brooklyn  belong  to  the  past.  None  of  the  three 
has  even  yet  entirely  emerged  from  the  fee-dividing  stage.  Syracuse,  with  a  smaller 
total  fee  income  than  any  of  them,  devotes  every  dollar  to  the  development  of  the 
fundamental  branches  and  has  fairly  earned  support  from  outside. 

Of  the  New  York  city  schools,  Columbia  and  Cornell  alone  have  at  this  moment 
any  financial  strength.  Neither  of  them,  indeed,  is  in  actual  possession  of  sufficient 
endowment;  but  there  is  little  reason  to  doubt  that  what  is  additionally  requisite 


NEW  YORK  277 

will  be  forthcoming.  New  York  University  is  much  less  secure.  Its  maintenance  at 
its  present  level  is  conditioned  on  adherence  to  a  lower  admission  standard  than  is 
scientifically  justifiable  or  educationally  necessary.  It  cannot  much  longer  resist  the 
upward  trend ;  for  its  scientific  faculty — and  thence  the  initial  stimulus  comes — is 
apt  to  chafe  under  the  limitations  which  the  lower  standard  imposes.  Whether  on 
the  higher  basis  the  school  will  be  a  permanent  factor  in  the  situation  is  thus  largely 
a  question  of  adequate  support  from  the  outside  in  the  next  few  years.  None  of  the 
other  local  schools  have  at  this  date  a  substantial  foundation  of  any  sort. 

The  ground  being  thus  cleared,  the  clinical  difficulty  still  presses.  Institutional 
competition  is  reduced;  but  personal  and  professional  competition  remain.  Why 
should  non-schoolmen  freely  retire  for  the  sake  of  schoolmen?  The  situation  is  curi- 
ously deadlocked.  The  school  faculties  are  not  now  made  up  on  educational  lines, 
— they  cannot  be.  If  the  number  of  schools  were  reduced  to  two  or  three,  it 
would  still  be  true  that  their  clinical  faculties  would  in  the  main  be  constituted  of 
men  very  much  like  the  more  important  men  omitted  from  them.  Such  being  the 
case,  the  hospitals  and  the  doctors  naturally  refuse  to  yield  to  the  universities;  and 
until  they  do  yield,  the  universities  cannot  freely  reconstruct  their  clinical  branches. 
The  faculty  men  would  themselves  doubtless  make  common  cause  with  the  outsiders 
as  against  a  university  which  asks  a  free  hand  in  order  to  bring  in  a  body  of  clinical 
teachers  from  the  outside.  The  usual  hospital  staff  will  not  vacate  for  the  present 
type  of  clinical  faculty,  because  the  faculty  lacks  commanding  scientific  and  peda- 
gogical preeminence;  nor  will  the  present  faculties  surrender  to  the  universities  for 
the  purpose  of  enabling  the  latter  to  fill  the  places  with  men  of  another  type. 

Under  these  circumstances,  palliation  may  perhaps  come  through  some  cooperative 
effort.  Tension  and  friction  will  at  least  decrease  as  the  number  of  schools  diminishes. 
Clinical  teaching  in  the  municipal  hospitals,  perhaps,  could  then  be  controlled  under 
some  form  of  federation.  The  vast  resources  of  these  great  institutions  might  under 
combined  management  form  a  great  postgraduate  and  special  clinic;  and  the  muni- 
cipal authorities  might  conceivably  relax,  for  the  common  benefit  of  a  single  organ- 
ization and  for  the  glory  of  a  great  enterprise,  restrictions  which  they  have  found 
necessary  in  dealing  with  several  institutions  engaged  simultaneously  in  training 
boys.  Unquestionably  such  action  would  bring  the  present  postgraduate  schools  into 
the  university,  where  they  ought  to  be. 

With  this  arrangement  consummated,  however,  the  schools  still  lack  teaching 
hospitals  in  which  the  undergraduate  student  can  be  vigorously  disciplined  while  his 
freely  chosen  teachers  are  themselves  engaged  in  intensive  clinical  research.  The 
teaching  hospital  must  be  in  close  geographical  proximity  to,  and  in  the  most  in- 
timate intercommunication  with,  the  scientific  laboratories.  In  the  case  of  Columbia, 
every  physical  and  educational  condition  is  already  satisfied  by  Roosevelt  Hospital: 
the  scientific  laboratories,  the  dispensary,  the  maternity  hospital,  are  on  one  side  of 
the  street;  the  general  hospital  on  the  other.  Together  they  would  form  an  ideally 


278  MEDICAL  EDUCATION 

compact  and  complete  plant.  That  they  are  not  so  operated  cannot  but  be  deplored 
as  a  tragic  mischance.  It  is  to  the  world  at  large  of  no  consequence  how  they  hap- 
pened to  drift  apart.  There  are  interests  at  stake  that  are  entitled  to  outweigh  all 
personal  and  historic  considerations. 

That  an  effective  affiliation  is  feasible  between  a  department  of  medicine  and  an 
endowed  hospital,  Western  Reserve  and  Lakeside  Hospital  assuredly  prove,  just  as 
Toronto  proves  the  same  as  between  a  medical  school  and  a  municipal  hospital.  There 
are  in  New  York  city  a  dozen  hospitals,  each  of  them  capable  of  becoming  a  teach- 
ing hospital  in  the  best  sense  of  the  term.  Their  usefulness  from  every  point  of  view 
would  increase  in  precisely  the  measure  in  which  they  lend  themselves  to  this  func- 
tion. They  are  already  comfortable  and  indeed  charming  retreats  for  the  sick  and 
injured.  Why  should  they  be  satisfied  to  be  that,  and  nothing  more?  They  are  favor- 
ably known  to  the  poor  and  to  the  philanthropic  of  New  York  city;  and  they  are 
deservedly  proud  of  their  repute.  Is  it  a  defect  of  intelligence  or  of  imagination  that 
prevents  them  from  reaching  out  for  more  substantial  laurels  ?  Perhaps  neither,  so 
much  as  a  disinclination  to  depersonalize  the  hospital  staff  management;  for  de- 
personalization,  in  hospital  management  as  in  faculty  appointments,  each  involving 
the  other,  is  the  condition  precedent  to  reconstitution  of  medical  education  in  New 
York.  Without  sacrificing  a  jot  of  their  local  distinction,  without  limiting  in  the 
slightest  degree  their  usefulness  to  the  sick  poor,  the  New  York  hospitals  may — any 
or  all  of  them — win  a  place  as  scientific  laboratories  beside  Guy^s  and  St.  Bartho- 
lomew's, the  Royal  Infirmary  of  Edinburgh,  the  Charite  of  Berlin,  the  Hotel-Dieu 
of  Paris.  Mount  Sinai,  the  Presbyterian,  St.  Luke's,  and  Roosevelt  Hospitals  might 
under  such  conditions  be  familiar  names  in  medical  science;  as  well  known  to  the  pro- 
gressive clinicians  of  St.  Petersburg,  Vienna,  Edinburgh,  St.  Louis,  and  San  Francisco, 
as  they  are  to  the  stricken  widows  of  the  East  Side  of  New  York  city  itself.  What  the 
Sloane  Maternity  Hospital  wisely  does  for  a  single  department,  the  general  hospitals 
can  do  for  general  medicine  and  surgery.  The  great  universities  on  the  ground  can 
be  trusted  with  the  opportunities  and  responsibilities  which  effective  affiliation  would 
give  them.  In  the  absence  of  such  affiliation,  separate  endowment,  procured  for  the  pur- 
pose, must  provide  teaching  hospitals  in  which  the  universities  will  be  supreme.  Would 
any  contend  that  these  hospitals  are  likely  to  be  less  admirably  conducted  than  the  un- 
attached hospitals  we  have  named?  or  that  the  university  faculty  of  medicine,  freely 
recruited,  is  likely  to  prove  a  less  competent  staff  than  present  methods  procure? 

The  issue  is  one  that  cannot  be  much  longer  fought  off:  Columbia  and  Cornell 
are  already  graduate  schools  in  medicine.  Their  laboratories  produce  a  high-grade 
student,  to  whom  the  university  is  bound  to  furnish  a  clinical  opportunity  of  the 
same  quality.  Neither  school  can  now  do  it.  An  effective  affiliation,  or  endowment 
adequate  to  support  a  teaching  hospital  and  a  scientific  medical  faculty,  is  therefore 
their  immediate  need  and  desert. 


NORTH  CAROLINA  279 

NORTH  CAROLINA 

t>         i   r-          o-iiOMui     XT        u          f     i.      •   •          (  1761  (Amer.Med.  Direct.).  Ratio,  1:121 6; 

Population,  2,142,084.  Number  of  physicians  j  1932V(polk)  u       1:ino; 

Number  of  medical  schools,  4. 

CHAPEL  HILL:  Population,  1181. 

(1)  UNIVERSITY  OF  NORTH  CAROLINA  MEDICAL  DEPARTMENT.  A  half-school.  Established 
1890.  An  organic  part  of  the  university. 

Entrance  requirement :  A  year  of  college  work — not,  however,  strictly  enforced  during 
this,  the  first  session  in  which  it  has  been  required. 

Attendance:  74;  95  per  cent  from  North  Carolina. 

Teaching  staff ':  15,  of  whom  10  are  professors  who  take  part  in  the  work  of  the  depart- 
ment. The  instructors  are  trained,  full-time  teachers. 

Resources  available  for  maintenance:  The  department  is  provided  for  in  the  univer- 
sity budget.  Its  budget  calls  for  $12,000.  Its  income  in  fees  is  $6500. 

Laboratory  facilities:  The  laboratories  at  Chapel  Hill  are  in  general  adequate  to 
good  routine  teaching  of  the  small  student  body.  The  equipment  covers  patho- 
logy, bacteriology,  histology,  physiology,  and  pharmacology.  Anatomy  is  inferior. 
Animals  are  provided  for  experimental  work.  The  general  scientific  laboratories 
of  the  university  are  excellent;  a  small  annual  appropriation  is  available  for  books 
and  periodicals.  The  work  is  intelligently  planned  and  conducted  on  modern  lines. 

Date  of  visit:  February,  1909. 

CHARLOTTE :  Population,  36,320. 

(2)  NORTH  CAROLINA  MEDICAL  COLLEGE.  Organized  1887,  it  has  given  degrees  since 
1893.  A  stock  company;  professorships  are  represented  by  stock  and  can  be  sold 
subject  to  the  concurrence  (never  yet  refused)  of  the  faculty. 

Entrance  requirement :  Nominal. 

Attendance:  94,  87  per  cent  from  North  Carolina. 

Teaching  staff:  32,  of  whom  19  are  professors,  13  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $8345  (estimated),  a  large 
part  being  required  to  carry  a  building  mortgage  and  to  retire  the  debt. 

Laboratory  facilities :  These  comprise  a  poor  chemical  laboratory,  containing  one  set 
of  reagents,  a  wretched  dissecting  room,  and  a  meager  outfit  for  pathology,  bac- 
teriology, and  histology.  There  is  no  museum,  no  library,  and  no  teaching  aids  of 
any  kind  whatever.  No  post-mortems  are  even  claimed. 


280  MEDICAL  EDUCATION 

Clinical  facilities:  The  school,  in  virtue  of  a  subscription,  holds  four  weekly  clinics  at 
a  colored  hospital  of  35  beds;  other  hospital  connections  are  unimportant.  Ob- 
stetrical cases  are  rare. 

There  is  a  poor  dispensary,  with  a  small  attendance,  in  the  school  building.  It 
occupies  a  fair  suite  of  rooms. 

Late  of  visit:  February,  1909. 

WAKE  FOREST:  Population,  900. 

(3)  WAKE  FOREST  COLLEGE  SCHOOL  OF  MEDICINE.  A  half-school.  Organized  1902.  An 
integral  part  of  Wake  Forest  College. 

Entrance  requirement:  Two  years  of  college  work,  actually  enforced,  but  resting  upon 
the  irregular  secondary  school  education  characteristic  of  the  section. 

Attendance:  53. 

Teaching  staff":  6  whole-time  instructors  take  part  in  the  work  of  the  department; 
two  of  them  devote  their  entire  time  to  medical  instruction. 

Resources  available  for  maintenance:  The  budget  is  part  of  the  college  budget.  Fees 
amount  to  $2225. 

Laboratory  facilities:  The  laboratories  of  this  little  school  are,  as  far  as  they  go, 
models  in  their  way.  Everything  about  them  indicates  intelligence  and  earnestness. 
The  dissecting-room  is  clean  and  odorless,  the  bodies  undergoing  dissection  being 
cared  for  in  the  most  approved  modern  manner.  Separate  laboratories,  properly 
equipped,  are  provided  for  ordinary  undergraduate  work  in  bacteriology,  patho- 
logy, and  histology,  and  the  instructor  has  a  private  laboratory  besides.  Chemistry 
is  taught  in  the  well  equipped  college  laboratory;  physiology  is  slight;  there  is  no 
pharmacology.  There  is  a  small  museum ;  animals,  charts,  and  books  are  provided. 

Date  of  visit:  February,  1909. 

RALEIGH :  Population,  20,533. 

(4)  LEONARD  MEDICAL  SCHOOL.  Colored.  Organized  1882.  An  integral  part  of  Shaw 
University. 

Entrance  requirement:  Less  than  four-year  high  school  education. 

Attendance:  125. 

Teaching  staff':  9,  of  whom  8  are  professors,  one  of  other  grade. 

Resources  available  for  maintenance:  Mainly  fees  and  contributions,  amounting  to 
$4721,  practically  all  of  which  is  paid  to  the  practitioner  teachers. 

Laboratory  facilities :  These  comprise  a  clean  and  exceedingly  well  kept  dissecting- 
room,  a  slight  chemical  laboratory,  and  a  still  slighter  equipment  for  pathology. 


NORTH  CAROLINA  281 

There  are  no  library,  no  museum,  and  no  teaching  accessories.  It  is  evident  that  the 
policy  of  paying  practitioners  has  absorbed  the  resources  of  a  school  that  exists 
for  purely  philanthropic  objects. 

Clinical  facilities:  These  are  hardly  more  than  nominal.  The  school  has  access  to  a 
sixteen-bed  hospital,  containing  at  the  time  of  the  visit  three  patients.  There  is 
no  dispensary  at  all.  About  thirty  thousand  dollars  are,  however,  now  available 
for  building  a  hospital  and  improving  laboratories. 

Date  of  visit;  February,  1909. 

General  Considerations 

THE  state  of  North  Carolina  makes  a  comparatively  satisfactory  showing  in  the 
matter  of  ratio  between  population  and  physicians ;  but  this  may,  perhaps,  in  some 
measure  be  due  to  the  fact  that  practitioners,  unlicensed  and  unregistered,  exist  un- 
disturbed in  the  remote  districts.  It  is  futile  to  maintain  a  low  standard  in  order  to 
prepare  doctors  for  those  parts ;  for  the  graduates,  instead  of  scattering  to  them,  hud- 
dle together  in  the  small  towns  already  amply  supplied.  It  is  admitted  that  all  eligible 
locations  are  overcrowded.  There  is  not  the  slightest  danger  that  the  necessary  sup- 
ply of  doctors  would  be  threatened  if,  for  instance,  the  practice  of  medicine  in  the 
state  were  pitched  on  the  plane  of  entrance  to  the  state  university ;  higher  than  that 
it  probably  ought  not  to  be  at  this  time. 

The  standard  suggested  —  any  real  standard  whatsoever,  indeed  —  would  quickly 
dispose  of  the  thoroughly  wretched  Charlotte  establishment.  No  clinical  school  would 
remain  in  the  state.  The  two  half-schools  —  at  Wake  Forest  and  at  the  state  univer- 
sity —  are  capable  of  doing  acceptable  work  within  the  limits  of  their  present  re- 
sources. Both  of  these  schools  now  require  college  work  for  entrance.  Is  this  step  to 
be  generally  recommended  at  this  time  to  southern  universities  with  medical  depart- 
ments ?  Without  attempting  to  arrive  at  a  decision,  it  may  be  pointed  out  that  there 
are  two  sides  to  the  question.  On  the  one  hand,  the  college  requirement  is  essential 
to  the  symmetrical  development  of  the  medical  curriculum ;  on  the  other,  a  good 
medical  course  can  be  given  at  an  actual  high  school  level,  provided  that  facilities 
and  teaching  are  developed  to  a  high  point  of  efficiency.  How  will  the  university 
best  serve  the  state, —  by  training  a  small  number  at  the  higher  level,  or  by  getting 
actual  control  of  the  state  situation  on  a  high  school  basis  before  pushing  ahead  to 
a  basis  just  generally  feasible  in  more  highly  developed  sections  of  the  country?  The 
University  of  Michigan  is  only  now  requiring  college  work  for  entrance ;  it  became 
a  strong  school  of  immense  influence  in  its  own  community  on  a  lower  basis.  Un- 
doubtedly it  is  right  now  to  go  to  the  higher  standard ;  perhaps  it  should  have  done 
so  earlier.  But  its  present  efficiency  and  influence  show —  as  McGill  and  Toronto 
show  —  that  if  a  lower  standard  is  felt  to  be  a  reason  for  better  teaching  and  not 
an  excuse  for  poor  teaching,  an  institution  unfavorably  located  for  the  initiation  of 


282  MEDICAL  EDUCATION 

the  higher  standard  can  do  good  work  on  the  lower  basis.  In  the  south  now  is  it 
more  important  to  destroy  commercial  schools  by  collecting  in  good  university 
institutions  a  sufficient  body  of  students,  or  to  provide  high-grade  teaching  for  a  few, 
leaving  utterly  wretched  teaching  for  the  vast  majority?  The  dilemma  is  worthy  of 
very  careful  consideration. 

A  word  as  to  the  colored  school  at  Raleigh.  This  is  a  philanthropic  enterprise  that 
has  been  operating  for  well-nigh  thirty  years  and  has  nothing  in  the  way  of  plant 
to  show  for  it.  Its  income  ought  to  have  been  spent  within ;  it  has  gone  outside,  to 
reimburse  practitioners  who  supposed  themselves  assisting  in  a  philanthropic  work. 
Real  philanthropy  would  have  taken  a  very  different  course.  As  a  matter  of  fact, 
Raleigh  cannot,  except  at  great  expense,  maintain  clinical  teaching.  The  way  to  help 
the  negro  is  to  help  the  two  medical  schools  that  have  a  chance  to  become  efficient, — 
Howard  at  Washington,  Meharry  at  Nashville. 


NORTH  DAKOTA 

Population,  536,103.  Number  of  physicians,  552.  Ratio,  1:971. 
Number  of  medical  schools,  1. 

GRAND  FORKS :  Population,  12,602. 

STATE  UNIVERSITY  OF  NORTH  DAKOTA,  COLLEGE  OF  MEDICINE.  Organized  1905.  A  half- 
school.  An  organic  part  of  the  state  university. 

Entrance  requirement:  Two  years  of  college  work. 
Attendance:  9. 

Teaching  staff:  9  professors  and  7  instructors  take  part  in  the  work  of  the  depart- 
ment. The  professor  of  bacteriology  is  State  Bacteriologist. 

Resources  available  for  maintenance:  The  department  shares  in  the  general  funds  of 
the  university.  Its  budget  amounts  to  $6300;  income  from  fees,  $450. 

Laboratory  facilities :  The  laboratory  of  bacteriology,  being  at  the  same  time  the 
public  health  laboratory  of  the  state,  is  well  equipped  and  very  active.  Subjects 
given  in  the  regular  university  laboratories  are  likewise  well  provided  for.  For  the 
specifically  medical  subjects — physiology,  pathology,  anatomy — the  provision  is 
slighter.  The  students  are,  of  course,  few.  A  library  and  museum  have  been  started. 

Dale  of  visit:  May,  1909. 

[See  South  Dakota,  "  General  Considerations,"  p.  SOI.] 


OHIO  283 

OHIO 

Population,  4,594,240.  Number  of  physicians,  7838.  Ratio,  1 :  586. 
Number  of  medical  schools,  8. 

CINCINNATI:  Population,  353,108. 

(1)  OHIO-MIAMI  MEDICAL  COLLEGE  OF  THE  UNIVERSITY  OF  CINCINNATI.  Organized  by 
merger,  1909.  An  organic  department  of  the  university. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 
Attendance:  197,  80  per  cent  from  Ohio. 

Teaching  staff':  126,  of  whom  50  are  professors,  76  of  other  grade.  There  are  nine 
professors  of  medicine  and  nine  professors  of  surgery  (not  including  gynecology). 
There  are  three  whole-time  teachers. 

Resources  available  for  maintenance:  Mainly  fees,  amounting  to  $26,345  (estimated). 

Laboratory  facilities:  The  university  has  so  recently  obtained  complete  control  that 
it  is  not  fair  to  make  an  inventory  of  the  situation  at  this  moment  in  a  critical 
spirit.  A  modern  outfit  adequate  to  routine  teaching  has  been  already  installed 
in  pathology,  bacteriology,  and  physiology.  The  subjects  are  taught  by  whole- 
time  modern  teachers.  Chemistry,  including  physiological  chemistry,  is  given  at  the 
university  by  whole-time  instructors.  Anatomy  is  as  yet  unorganized. 

Clinical  facilities :  These  are  likewise  in  a  state  of  transition,  not  only  because  of  the 
recent  formation  of  the  department,  but  further,  because  the  city  has  just  begun 
the  erection  of  a  new  hospital,  whose  exact  relation  to  the  university  remains  to 
be  determined.  There  is  an  apparent  disposition  to  make  the  relation  close  enough 
to  be  educationally  effective.  In  that  event,  the  university  must  on  its  side  reor- 
ganize its  clinical  departments.  The  various  schools  may  have  disappeared,  but 
their  professorial  titles  remain.  There  must  be  a  single  professor  of  medicine,  a 
single  professor  of  surgery,  etc.,  if  the  hospital  facilities  in  prospect  are  to  be  de- 
served and  properly  utilized. 

The  school  dispensary  awaits  proper  organization. 

Date  of  visit :  December,  1909. 

(2)  ECLECTIC  MEDICAL  INSTITUTE.  Chartered  1845.  An  independent  institution. 

Entrance  requirement:  For  Ohio  students,  a  four-year  high  school  education  or  its 
equivalent.  Students  from  outside  states  are  not  held  to  the  same  standard. 

A  ttendance :  86. 

Teaching  staff:  24,  of  whom  one-half  are  professors.  None  of  the  instructors  devotes 
his  entire  time  to  teaching. 


284  MEDICAL  EDUCATION 

Resources  available  for  maintenance:  Fees,  amounting  to  $7500. 

Laboratory  facilities:  A  new  building  has  just  been  provided;  it  contains  an  ordinary 
laboratory  for  elementary  inorganic  chemistry  and  a  good  dissecting-room.  Sepa- 
rate laboratories,  as  yet  meagerly  equipped,  are  set  aside  for  histology,  pathology, 
and  bacteriology.  There  is  a  small  museum  and  a  small  collection  of  books,  but 
practically  no  other  teaching  accessories.  The  course  of  instruction  is  not  graded. 

Clinical  facilities:  The  school  adjoins  the  Seton  Hospital,  with  which  it  is  affiliated. 
This  institution  has  60  beds,  of  which  not  over  24  are  usable, — those  mostly  sur- 
gical. Little  medical  material  is  accessible.  The  teaching  is  carried  on  mainly  in 
the  amphitheater. 

Sophomores  are  required  to  attend  public  clinics  at  the  city  hospital  (never  given 
by  eclectic  teachers),  but  the  school  does  not  know  whether  they  attend  or  not. 

A  dispensary  with  a  small  attendance  is  connected  with  the  hospital. 
Datet  of  vitit* :  December,  1909;  April,  1910. 

(3)  PULTE  MEDICAL  COLLEGE.  Homeopathic.  Established  1872.  An  independent  in- 
stitution. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 
Attendance:  16. 

Teaching  staff:  36,  of  whom  24  are  professors,  12  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  SI  325  (estimated). 

Laboratory  facilities :  Anything  more  woe-begone  than  the  laboratories  of  this  insti- 
tution would  be  difficult  to  imagine.  The  dissecting-room  is  a  dark  apartment  in 
the  basement,  in  which  (December  14)  the  year's  dissecting  had  not  yet  begun; 
but  the  teaching  of  anatomy  was  not  therefore  halted.  A  disorderly  room  with  a 
small  amount  of  morbid  material  and  equipment  is  known  as  the  pathological  and 
bacteriological  laboratory.  The  chemical  laboratory  contains  a  few  desks,  with  re- 
agent bottles,  mostly  empty.  There  are  a  few  old  books  in  the  faculty-room.  No 
charts,  museum,  models,  or  other  teaching  accessories  are  to  be  seen. 

Clinical  facilities :  There  was  formerly  a  hospital  in  the  same  building,  but  it  is  now 
closed.  The  school  claims  to  hold  clinics  at  certain  private  institutions,  in  which, 
however,  the  work  is  mainly  surgical  and  the  cases  not  free.  Except  by  attending 
amphitheater  clinics  at  the  city  hospital,  it  is  not  clear  that  the  Pulte  students 
can  regularly  see  any  hospital  medical  cases  at  all. 

There  is  an  inexpressibly  bad  dispensary  in  the  school  building. 

Date  of  visit:  December,  1909. 


OHIO  285 

CLEVELAND:  Population,  522,475. 

(4)  CLEVELAND  HOMEOPATHIC  MEDICAL  COLLEGE.  Organized  1849.  An  independent 
institution. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 
Attendance:  46. 

Teaching  staff":  61,  of  whom  30  are  professors,  31  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  $5750. 

Laboratory  facilities :  These  comprise  a  good  laboratory  for  physiology,  in  which 
vigorous  teaching  was  in  progress.  In  other  subjects — chemistry,  anatomy,  patho- 
logy, and  bacteriology — the  provision  is  only  fair.  There  are  several  cases  of  old 
medical  books  in  the  office. 

Clinical  facilities:  These  are  limited  to  the  City  Hospital, — a  large  institution  three 
miles  distant,  in  which  one-fifth  of  the  material  is  assigned  to  this  school.  Adjoin- 
ing the  school  building  is  a  homeopathic  hospital,  with  which  the  school  was 
once  intimately  connected;  they  have  now  drifted  apart. 

Several  rooms  in  the  basement  and  on  the  first  floor  of  the  college  building  are  used 
for  a  dispensary.  Their  equipment  is  poor;  no  complete  or  lasting  records  are  kept. 

Date  of  visit:  December,  1909. 

(5)  WESTERN  RESERVE  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1843;  in  1881 
joined  Western  Reserve  University,  of  which  it  is  now  an  organic  part. 

Entrance  requirement :  Three  years  of  college  work. 
Attendance:  98,  of  whom  70  per  cent  are  from  Ohio. 

Teaching  staff:  100,  of  whom  18  are  professors,  82  of  other  grade.  The  laboratories 
are,  with  the  exception  of  anatomy,  manned  with  teachers  giving  their  entire  time 
to  the  school. 

Resources  available  for  maintenance:  The  department  has  endowments  aggregating 
$784,865.  Its  income  from  fees  is  $11,000.  Its  budget  calls  for  $63,000. 

Laboratory  facilities :  Excellent  laboratories,  in  which  teaching  and  research  are  both 
vigorously  prosecuted,  are  provided  for  all  the  fundamental  scientific  branches.  A 
special  endowment  carries  the  department  of  experimental  medicine.  Books,  mu- 
seum, and  other  teaching  accessories,  all  in  abundance,  are  at  hand. 

Clinical  facilities :  From  the  faculty  of  the  school  is  appointed  the  staff  of  Lakeside 
Hospital,  an  endowed  institution  of  215  available  beds,  thoroughly  modern  in  con- 
struction and  equipment.  The  school  has  erected  a  clinical  laboratory  on  the 
premises,  so  that  close  correlation  of  bedside  and  laboratory  work  is  easily  attain- 
able. The  relation  of  the  two  institutions  has  progressively  become  more  intimate, 


286  MEDICAL  EDUCATION 

and  in  the  same  measure  mutually  more  helpful.  The  situation  is  one  that  might 
be  reproduced  with  infinite  advantage  in  New  York,  Boston,  Chicago,  etc. 

In  addition,  the  school  holds  clinics  at  the  City  Hospital,  Charity  Hospital, 
St.  Ann's  Maternity  Hospital,  etc.  It  commands,  therefore,  all  the  material  that  is 
necessary.  It  requires  now  only  additional  endowment  in  order  that  it  may  com- 
pletely command  the  time  of  clinical  teachers. 

The  Lakeside  Dispensary,  admirably  conducted,  is  used  by  the  school  on  the 
same  terms  as  the  Lakeside  Hospital.  The  attendance  is  large  and  varied.  There 
is  also  an  excellent  dispensary  connected  with  the  Charity  Hospital. 
Date  of  visit:  December,  1909. 

(6)  COLLEGE  OF  PHYSICIAKS  AND  SURGEONS.*  Organized  1863;  since  1896  nominally 
the  medical  department  of  Ohio  Wesleyan  University. 

Entrance  requirement:  Four-year  high  school  education  or  equivalent. 
Attendance: 89,  92  per  cent  from  Ohio. 

Teaching  staff:  Numbers  59,  of  whom  18  are  professors,  41  of  other  grade.  There 
are  no  teachers  devoting  their  entire  time  to  the  school. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $9520  (estimated). 

Laboratory  facilities :  These  cover  only  routine  needs  in  chemistry,  anatomy,  bacteri- 
ology, and  pathology.  There  is  a  meager  supply  of  apparatus  for  experimental  physi- 
ology, no  museum,  few  books,  and  little  else  in  the  way  of  teaching  accessories. 

Clinical  facilities:  The  school  holds  clinics  at  the  City  Hospital  during  four  months, 
and  at  several  private  institutions,  in  which,  however,  the  work  is  largely  surgi- 
caL  It  has  access  to  a  fair  amount  of  material,  but  under  limitations  that  greatly 
impair  its  value.  All  the  hospitals  are  at  considerable  distance  from  the  school ; 
none  of  them  is  provided  with  clinical  laboratories  for  student  use.  In  conse- 
quence, the  teaching  is  of  the  discontinuous  demonstrative  type.  Close  contact  of 
student  with  patient  or  systematic  following  of  cases  is  impossible.  Obstetrical 
work  is  limited  to  an  out-patient  service. 

The  dispensary  is  small  and  poorly  organized.  The  attendance  is  slight 

Date  ofvitit:  December,  1909. 

COLUMBUS:  Population,  158,649. 

(7)  STARLING-OHIO  MEDICAL  COLLEGE.  Formed  by  merger  in  1907.  An  independent 
institution. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 

1  As  this  report  goes  to  press,  it  is  announced  that  this  school  has  been  consolidated  with  the  Medical 
Department  of  Western  Reserve  University. 


OHIO  287 

Attendance:  220. 

Teaching  staff":  60,  of  whom  32  are  professors,  28  of  other  grade.  There  are  no 
teachers  giving  their  whole  time  to  medical  instructions.  Some  of  the  laboratory 
instruction  is  given  by  men  who  also  teach  in  Ohio  State  University. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $27,500. 

Laboratory  facilities :  The  school  has  a  large  plant.  Laboratories  adequately  equipped 
for  routine  instruction  are  provided  for  anatomy,  chemistry, physiological  chemistry, 
bacteriology,  pathology,  and  histology.  There  is  no  experimental  pharmacology. 
Student  assistants  are  employed.  There  is  no  evidence  anywhere  of  original  activity 
or  interest.  The  school  has  a  library,  museum,  and  a  supply  of  teaching  accessories. 

Clinical  facilities:  The  school  controls  two  hospitals,  in  one  of  which — containing, 
however,  only  40  usable  beds — it  might  introduce  modern  teaching  methods.  The 
other  hospital,  containing  150  beds,  is  a  Catholic  institution.  Neither  hospital  is 
built,  organized,  or  equipped  with  the  necessities  of  teaching  in  view.  No  pavilion 
for  contagious  diseases  is  accessible.  The  city  has  thus  far  done  nothing  to  provide 
proper  hospital  facilities  for  the  sick  poor.  The  state  institutions  are,  however, 
available. 

The  school  dispensaries  enjoy  an  abundance  of  material,  but  lack  equipment, 
organization,  and  oversight. 

The  conditions  described  are  doubtless  to  some  extent  due  to  the  difficulty  of 
welding  two  schools  into  one.  Vigorous  measures  might,  however,  produce  here  a 
good  institution. 
Date  of  visit :  December,  1909. 

TOLEDO:  Population,  178,753. 

(8)  TOLEDO  MEDICAL  COLLEGE.  Organized  1883.  The  medical  department  of  Toledo 
University,  a  municipal  institution  of  uncertain  status  and  without  substantial 
resources. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 
Attendance:  32. 

Teaching-  staff":  48,  of  whom  16  are  professors,  32  of  other  grade.  No  one  gives  entire 
time  to  medical  classes. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $3240  (estimated). 

Laboratory  facilities:  The  school  has  nothing  that  can  be  fairly  dignified  by  the  name 
of  laboratory.  Separate  rooms,  badly  kept  and  with  meager  equipment,  are  pro- 
vided for  chemistry,  anatomy,  pathology,  and  bacteriology.  The  class-rooms  are 
bare:  no  charts,  bones,  skeleton,  or  museum  are  in  evidence.  There  is  a  small 
library  in  the  office. 


288  MEDICAL  EDUCATION 

Clinical  facilities :  These  are  entirely  inadequate.  The  school  formerly  held  clinics  at 
the  County  Hospital,  but  the  connection  has  been  severed  in  consequence  of  a 
political  overturning.  It  still  has  access  to  two  hospitals:  in  one  of  them  it  holds 
a  small  number  of  clinics,  both  medical  and  surgical ;  in  the  other  it  conducts  a 
surgical  clinic  twice  a  week.  In  neither  of  them  can  such  material  as  exists  be 
thoroughly  used  for  teaching  purposes. 

There  is  a  wretched  little  dispensary  in  the  college  building. 

Date  ofvitit:  February,  1910. 

General  Considerations 

OF  the  eight  medical  schools  of  Ohio  one  has  already  won  a  permanent  place  and 
two  more  have  possibilities.  The  present  administration  of  the  state  law  is  tighten- 
ing about  the  other  five,  and  there  is  every  reason  to  suppose  that  they  will  all  shortly 
have  to  submit  to  the  inevitable.  Just  why  the  law  should  be  tenderly  applied  is  not 
clear.  The  state  is  rich,  prosperous,  and  well  supplied  with  secondary  schools,  though 
the  competition  of  state-supported  institutions  has  hitherto  interfered  with  their 
systematic  organization ;  and  two  or  three  doctors  now  contest  every  field  capable  of 
decently  supporting  one.  It  would  appear  feasible  at  once  to  enforce  a  genuine  four- 
year  high  school  preliminary  and  forthwith  to  move  towards  the  higher  standard  just 
declared  in  Indiana. 

The  most  prosperous  universities  of  the  state  are,  from  the  standpoint  of  medical 
education,  fortunately  situated :  Western  Reserve,  at  Cleveland,  the  Ohio  State  Uni- 
versity, at  Columbus,  the  University  of  Cincinnati,  at  Cincinnati.  Of  the  future  of 
Western  Reserve  there  is  no  doubt.  It  is  already  one  of  the  substantial  schools  of 
the  country.  Its  clinical  problem  has  been  solved  on  lines  that  create  a  precedent 
worthy  to  be  generally  followed.  Its  financial  resources  are,  however,  decidedly  in- 
ferior to  its  deserts  and  ideals.  A  keener  appreciation  of  its  worth  must  surely  result 
in  substantial  improvement  of  its  position  in  this  respect. 

The  state  of  Ohio  has  a  duty  in  reference  to  medical  education  and  public  health, 
the  performance  of  which  is  made  comparatively  simple  by  the  appropriate  location 
at  Columbus  of  the  most  important  of  its  three  state  universities.  As  for  the  rest,  it 
is  a  question  of  money  and  ideals.  The  plant  of  the  Starling-Ohio  school  can  prob- 
ably be  readily  secured.  Its  educational  value  though  not  large  may  be  readily 
increased;  its  laboratories  could  be  easily  consolidated,  remodeled,  and  reorganized 
under  trained  teachers  with  paid  assistants.  On  the  clinical  side,  the  difficulties  are 
more  serious,  though  not  improbably  the  present  Protestant  Hospital  could  be  de- 
veloped into  a  good  teaching  hospital  if  the  state  supplied  the  necessary  funds.  The 
problem  of  procuring  clinical  teachers  of  modern  type  would  still  remain. 

The  city  of  Cincinnati  seems  definitely  committed  to  the  project  of  a  municipal 
university.  Coincidently,  the  building  of  the  new  municipal  hospital  furnishes  an 
unusual  opportunity  to  its  medical  department.  A  municipal  university  has  two  ob- 


OKLAHOMA  289 

vious  sources  of  support:  taxation  may  well  be  employed  at  least  to  maintain  de- 
partments calculated  to  meet  local  needs, —  industrial,  social,  or  cultural;  the  pride 
of  its  citizens  ought  to  supplement  its  tax  income  by  way  of  supporting  departments 
like  medicine,  whose  main  function  can  hardly  be  circumscribed  by  local  considera- 
tions. The  future  of  the  medical  department  is  thus  likely  to  depend  on  the  intelli- 
gence and  munificence  of  the  private  benefactors  of  the  university.  The  city  can  con- 
tribute its  hospital  and  part  of  the  current  maintenance.  Thus  far  the  university  has 
surely  deserved  well  for  its  success  in  bringing  together  the  rival  schools  which  long 
divided  and  demoralized  the  field;  the  schools  themselves  made  generous  sacrifice  of 
property  rights  in  order  to  consummate  the  merger.  It  should,  however,  be  added 
that  this  impersonal  attitude  has  yet  to  be  applied  to  the  organization  of  the  faculty. 
Property  rights  were  yielded;  professorial  titles  remain.  Now,  if  the  professors  of  the 
medical  department  of  the  University  of  Cincinnati  really  desire — as  the  coming  to- 
gether of  the  schools  signifies — that  there  should  be  one  strong  medical  school  in 
the  city,  they  must  realize  that  a  school  in  which  there  are  nine  professors  of  medi- 
cine and  nine  professors  of  surgery  is  as  yet  without  organization.  They  ought  there- 
fore to  surrender  their  titles  to  the  university  with  the  request  that  each  clinical 
department  be  reconstructed  by  placing  at  its  head  the  single  individual  marked  out 
for  the  position,  in  the  best  judgment  of  the  trustees  of  the  university,  by  his  scien- 
tific eminence  and  pedagogic  skill. 

OKLAHOMA 

Population,  1,592,401.  Number  of  physicians,  2703.  Ratio,  1:  589. 
Number  of  medical  schools,  2. 

NORMAN:  Population,  3389. 

(1)  STATE  UNIVERSITY  OF  OKLAHOMA,  SCHOOL  OF  MEDICINE.  Organized  1898.  A  half- 
school.  An  integral  part  of  the  university. 

Entrance  requirement:  One  year  of  college  work  in  sciences. 
Attendance:  22,  all  but  2  from  Oklahoma. 

Teaching  staff":  The  instruction  is  given  mainly  by  whole-time  university  teachers, 
two  of  whom  devote  their  entire  time  to  the  department ;  the  dean  of  the  depart- 
ment is  a  practising  physician. 

Resources  available  for  maintenance:  The  department  is  supported  out  of  the  general 
revenues  of  the  university;  fees  amount  to  $600. 

Laboratory  facilities:  Modest  laboratories,  adequate  to  routine  work,  are  provided  in 
anatomy,  physiology,  physiological  chemistry,  pharmacology,  histology,  pathology, 


290  MEDICAL  EDUCATION 

and  bacteriology.  The  laboratory  of  the  state  board  of  health  is  in  the  depart- 
ment. There  are  a  small  museum  and  a  small  departmental  library. 
Date  ofvitit:  November,  1909. 

OKLAHOMA  CITY:  Population,  49,899. 

(2)  EPWORTH  COLLEGE  OF  MEDICINE.*  Organized  1904.  A  stock  company,  nominally 
the  medical  department  of  Epworth  University. 

Entrance  requirement:  Nominal. 

Attendance:  51. 

Teaching  staff":  42,  of  whom  28  are  professors,  14  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $4285. 

Laboratory  facilities :  These  are  hardly  more  than  nominal:  a  little  apparatus  has 
been  procured  for  each  of  the  several  subjects,  but  all  is  disorderly  and  neglected. 

Clinical  facilities:  Clinics  are  held  in  a  private  hospital,  where  perhaps  30  beds,  mostly 
surgical,  are  available. 

There  is  no  school  dispensary. 

Data  of  vitit:  November,  1909. 

General  Considerations 

THE  new  commonwealth  of  Oklahoma  may,  if  wise,  avoid  most  of  the  evils  which  this 
report  has  described;  for  though  they  have  already  appeared,  they  have  not  taken  deep 
root.  Immigration — of  physicians,  among  others — has  been  so  rapid  that  the  state 
has  easily  three  times  as  many  doctors  as  it  needs.  They  pour  in  from  the  schools  of 
St.  Louis,  Kansas  City,  and  Chicago.  If,  however,  the  state  wishes  a  high-grade  sup- 
ply only,  it  must  speedily  define  a  standard  such  as  will  (1)  suppress  commercial 
schools, — as,  for  example,  that  now  nominally  belonging  to  Epworth  University, — 
and  (2)  by  the  same  action  exclude  inferior  doctors  trained  elsewhere.  Having  done 
this,  only  an  institution  with  considerable  resources,  derived  either  from  taxes  or  from 
endowment,  will  even  attempt  to  conduct  a  medical  school  in  the  state :  which  is  as  it 
should  be. 

The  state  university  is  of  course  marked  out  for  the  work.  Its  present  modest  be- 
ginning must  be  developed.  Perhaps  it  will  have  at  once  to  occupy  Oklahoma  City 
with  a  clinical  department  so  as  to  obtain  control  of  the  field ;  though,  if  its  sole 
right  could  be  established  without  that,  the  project  might  well  be  delayed  for  a 
time.  A  good  medical  school  is  so  costly  that  a  new  university  does  not  want  to  an- 
ticipate the  responsibility.  Possible  expenditures  on  such  a  department  have  in  a  way 
been  crippled  in  advance  by  the  absurd  duplication  of  state  institutions.  There  are 

1  As  this  report  goes  to  press,  it  is  stated  that  this  school  has  been  consolidated  with  the  medical 
department  of  the  state  university,  which  thus  becomes  a  complete  school  of  the  divided  type. 


OREGON  291 

26  state-supported  educational  institutions  in  Oklahoma.  In  other  respects  the  people 
of  the  state  have  been  quick  to  profit  by  the  experience  of  other  sections.  Oklahoma 
City  has  not  in  its  building  recapitulated  the  phases  of  growth  elsewhere.  Its  streets 
are  of  asphalt,  its  large  buildings  are  fire-proof,  their  plumbing  modern ;  they  have 
begun  with  enamel,  not  with  tin  or  zinc,  bathtubs.  Why  do  they  not  in  the  same  way 
avoid  the  weary  and  costly  errors  in  educational  organization  that  the  states  about 
them  have  one  after  the  other  made  ?  Ordinary  intelligence,  surveying  the  states  of  the 
middle  west  to-day  after  their  educational  experience  of  the  last  thirty  years,  could 
reduce  its  lessons  to  a  few  simple  propositions  which  would  be  universally  accepted. 
No  two  judges  would  differ  as  to  the  principle  that  state  institutions  of  higher 
learning  should  be  concentrated  in  a  town  of  assured  future;  that  proprietary  medical 
schools  should  be  forbidden,  etc.  The  older  states  are  painfully  correcting  or  paying 
for  their  blunders:  should  Oklahoma,  to  soothe  the  local  pride  of  this  little  town  or 
that,  run  up  a  bill  of  the  same  sort  ? 

OREGON 

Population,  505,339.  Number  of  physicians,  782.  Ratio,  1:  646. 
Number  of  medical  schools,  2. 

PORTLAND:  Population,  131,508. 

(1)  UNIVERSITY  OF  OREGON  MEDICAL  DEPARTMENT.  Organized  1887.  Nominally  the 
medical  department  of  the  state  university. 

Entrance  requirement:  Less  than  a  high  school  education. 
Attendance:  72,  65  per  cent  from  Oregon. 

Teaching  staff:  41,  of  whom  14  are  professors,  27  of  other  grade.  No  teachers  de- 
vote full  time  to  the  school. 

Resources  available  for  maintenance:  An  annual  appropriation  of  $1000  from  the 
funds  of  the  state  university,  and  fees  amounting  to  $8000  (estimated). 

Laboratory  facilities :  The  school  occupies  a  frame  building,  wretchedly  kept.  It  has 
one  good  laboratory,  that  of  bacteriology,  conducted  by  the  city  bacteriologist. 
Other  branches,  like  chemistry,  anatomy,  pathology,  and  histology,  are  provided 
in  the  usual  perfunctory  manner.  There  is  a  scanty  equipment  in  physiology;  one 
thousand  to  fifteen  hundred  books,  mostly  old  text-books,  form  the  library.  Other 
teaching  accessories  there  are  none. 

Clinical  facilities :  The  school  has  access  by  courtesy  to  two  hospitals,  in  which  stu- 
dents may  look  on.  They  cannot  work  in  the  clinical  laboratories  of  the  hospital, 
and  there  is  no  clinical  laboratory  at  the  school.  Obstetrical  cases  are  entirely 
insufficient. 


292  MEDICAL  EDUCATION 

The  dispensary  has  an  attendance  varying  from  two  to  seven  daily. 
Dot*  of  visit:  May,  1909. 

SALEM:  Population,  7287.1 

(2)  WILLAMETTE  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1865.  An  inde- 
pendent institution  in  all  but  name. 

Entrance  requirement:  Less  than  a  high  school  education. 

Attendance:  29,  86  per  cent  from  Oregon. 

Teaching-  staff":  16,  of  whom  15  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $3580  (estimated). 

Laboratory  facilities:  The  school  has  a  fairly  well  equipped  laboratory  for  bacteri- 
ology and  histology;  a  small  laboratory,  with  little  material  and  no  running  water 
for  chemistry;  and  a  dissecting-room.  There  are  no  museum,  no  books,  no  other 
teaching  accessories.  Inquiry  on  the  subject  of  physiology  elicited  the  response 
that  the  "apparatus  is  in  a  physician's  office  downtown." 

Clinical  facilities:  These  are  hardly  more  than  nominal.  Students  have  some  access 
to  a  private  hospital  of  30  beds  in  Salem  and  to  the  State  Asylum  and  Peniten- 
tiary a  few  miles  distant.  "Medical  clinics  depend  on  cases."  Obstetrical  cases 
"depend  on  private  practice." 

There  is  no  dispensary  at  all. 
Datt  ofvifit:  May,  1909. 

General  Considerations 

NEITHER  of  these  schools  has  either  resources  or  ideals;  there  is  no  justification  for 
their  existence.  The  entire  coast  is  oversupplied  with  doctors  by  immigration ;  unless 
something  better  can  be  made  than  can  be  thus  readily  obtained,  the  state  will  do 
well  to  let  the  field  lie  fallow. 

The  Salem  school  is  an  utterly  hopeless  affair,  for  which  no  word  can  be  said.  Port- 
land may  conceivably  some  day  maintain  a  distant  department  of  the  state  uni- 
versity. Until,  however,  the  financial  strength  of  the  state  university  permits  it  to 
develop  there  a  school  equal,  for  instance,  to  that  which  the  University  of  Texas  sup- 
ports at  Galveston,  it  has  no  right  to  allow  a  group  of  local  doctors  to  exploit  its 
name  in  the  conduct  of  a  low-grade  proprietary  institution.  That  out  of  its  own 
slender  revenues  it  should  divert  a  thousand  dollars  annually  into  the  coffers  of  this 
concern  is  well-nigh  incredible. 


1  Not  estimated  by  U.  S.  Census  Bureau. 


PENNSYLVANIA  293 

PENNSYLVANIA 

Population,  7,032,915.  Number  of  physicians,  11,056.  Ratio,  1:636. 
Number  of  medical  schools,  8,  plus  1  postgraduate  school. 

PHILADELPHIA:  Population,  1,540,430. 

(1)  UNIVERSITY  OF  PENNSYLVANIA  DEPARTMENT  OF  MEDICINE.  Organized  1765.  An 
organic  part  of  the  university. 

Entrance  requirement:  One  year  of  college  work,  in  which,  however,  conditions  have 
been  very  freely  allowed. 

Attendance:  546,  63  per  cent  from  Pennsylvania. 

Teaching  staff:  157,  of  whom  26  are  professors,  131  of  other  grade.  The  laboratory 
instructors,  with  a  few  of  their  assistants,  devote  their  entire  time  to  teaching  and 
research. 

Resources  available  for  maintenance:  The  department  shares  the  general  funds  of  the 
university.  Its  budget — exclusive  of  the  hospital  and  dispensary — is  $131,255; 
the  income  from  fees  is  $104,612. 

Laboratory  facilities:  Five  separate  well  equipped  buildings  are  provided  for  the 
laboratories  of  the  department:  the  first  for  histology,  embryology,  etc.;  the  sec- 
ond— new  and  admirably  adapted  to  its  purposes — for  pathology,  physiology, 
and  pharmacology;  the  third  for  chemistry  and  anatomy,  with  a  deservedly 
famous  anatomical  museum;  the  fourth  for  hygiene;  the  fifth  is  the  clinical 
laboratory,  never  as  yet  adequately  supported.  Near  by  is  the  Wistar  Insti- 
tute, open  to  graduate  students  for  research  in  anatomy.  The  department  pos- 
sesses an  admirable  library.  Its  scientific  faculty  has  been  recently  strengthened 
by  the  creation  of  chairs  of  physiological  chemistry  and  experimental  medicine, 
specially  endowed.  The  department  has,  therefore,  an  admirable  material  equip- 
ment. 

Clinical  facilities :  The  University  Hospital  of  350  beds,  of  which  280  are  available 
for  instruction,  is  contiguous  to  the  laboratories.  There  is  a  separate  maternity 
pavilion  of  50  beds.  Considerable  use  is  also  made  of  several  other  hospitals,  not- 
ably the  Philadelphia  General  Hospital  and  the  Pennsylvania  Hospital,  extra- 
mural instruction  being  given  at  the  latter.  The  recently  established  Phipps  In- 
stitute for  tuberculosis  is  also  now  part  of  the  clinical  plant.  The  equipment  of 
the  department  thus  fully  satisfies  all  essential  conditions. 

Two  dispensaries  are  used,  one  at,  the  other  at  a  distance  from,  the  university. 
Abundant  material  is  thus  obtained. 

Date  of  visit:  March,  1909. 


294  MEDICAL  EDUCATION 

(2)  JEFFERSON  MEDICAL  COLLEGE.  Organized  1825.  An  independent  institution. 

Entrance  requirement:  A  high  school  education  or  its  equivalent.  Of  all  independent 
schools  outside  New  York  state,  this  institution  comes  nearest  to  obtaining  its 
published  entrance  requirements.  It  lacks,  however,  an  organization  adapted  to  the 
evaluation  of  secondary  school  credentials.  A  fair  percentage  of  those  admitted 
have  had  some  college  work. 

Attendance:  591,  of  whom  57  per  cent  are  from  Pennsylvania. 

Teaching  staff:  122,  of  whom  22  are  professors,  100  of  other  grade.  Seven  instructors 
devote  their  entire  time  to  the  school. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $102,995.  Part  of  the 
school  income  is,  however,  diverted  in  order  to  pay  off  building  mortgages.  The 
hospital  has  independent  sources  of  support. 

Laboratory  facilities :  An  attractive  building  contains  separate  laboratories  for  ana- 
tomy, physiology,  chemistry,  pathology,  histology,  bacteriology,  and  pharmacy. 
The  equipment  is  in  general  modern  and  adequate  to  the  needs  of  undergraduate  in- 
struction ;  in  certain  departments,  e.  g.,  anatomy  and  bacteriology,  additional  activ- 
ity is  in  progress.  Lack  of  space  and  means  restricts  the  school  to  undergraduate 
teaching.  There  are  an  attractive  library,  museum,  and  other  teaching  accessories. 

Clinical  facilities :  The  Jefferson  Hospital — a  modern  structure,  with  223  teaching 
beds,  belonging  to  the  institution — adjoins  the  laboratory  building;  it  is  con- 
nected with  a  dispensary  which  supplies  an  abundance  of  material.  The  maternity 
department,  with  17  beds,  occupies  a  separate  building.  Students  are  freely  ad- 
mitted to  the  hospital  wards  and  its  clinical  laboratory. 

The  plant  of  the  institution  is  therefore  modern  and  compact. 

Dat«  of  visit:  March,  1909. 

(3)  MEDICO-CHIRURGICAL  COLLEGE  OF  PHILADELPHIA.  Organized  1881.  An  indepen- 
dent school. 

Entrance  requirement:  Less  than  a  four-year  high  school  education. 
Attendance:  480,  82  per  cent  from  Pennsylvania.  ^ 

Teaching  staff":  109,  of  whom  23  are  professors,  86  of  other  grade.  No  teachers  devote 
their  entire  time  to  medical  instruction;  three  teachers,  however,  devote  themselves 
entirely  to  the  school,  if  the  dental  and  pharmacy  departments  are  counted  in. 

Resources  available  for  maintenance:  Fees,  amounting  to  $48,281. 

Laboratory  facilities :  Well  equipped  for  ordinary  undergraduate  teaching  are  the 
laboratories  of  physiology,  chemistry,  pathology,  and  bacteriology.  Anatomy  is 
practically  limited  to  dissecting,  with  some  drawing  and  modeling,  the  professor 


PENNSYLVANIA  295 

being  a  practitioner.  There  is  no  museum  beyond  necessary  specimens  for  patho- 
logical work.  There  is  a  library  at  the  College  Club.  Students  in  dentistry,  pharmacy, 
and  medicine  mingle  in  a  number  of  classes.  Student  assistants  are  freely  used.  Ex- 
cept in  bacteriology,  little  or  no  effort  is  made  to  cultivate  original  scientific 
activity;  great  stress  is  laid  on  effective  drill. 

Clinical  facilities :  The  school  has  entire  control  of  its  own  hospital,  of  180  available 
beds,  which  is  in  close  proximity  to  the  other  buildings.  The  Maternity  Hospital  is 
near  by.  Ward  and  section  methods  are  in  use.  Classes  are  also  held  in  the  usual 
manner  at  other  hospitals. 

The  dispensary  attendance  is  large. 

Date  ofvitit:  March,  1909. 

(4)  TEMPLE  UNIVERSITY,  DEPARTMENT  OF  MEDICINE.  Organized  1901. 
Entrance  requirement:  Less  than  a  four-year  high  school  education. 
Attendance:  136. 

Teaching-  staff:  85,  of  whom  15  are  professors,  70  of  other  grade.  There  are  no  full- 
time  teachers. 

Resources  available  for  maintenance:  Fees  only,  amounting  to  $17,000  (estimated). 

Laboratory  facilities :  These  are  entirely  inadequate  and  in  some  departments  quite 
wretched.  There  is  an  ordinary  elementary  laboratory  for  chemistry ;  a  single  room 
with  slight  equipment  for  histology,  pathology,  and  bacteriology,  and  only  a 
demonstration  outfit  for  physiology.  The  dissecting-room  is  in  bad  condition. 
There  is  a  small  museum  and  a  library  of  several  thousand  volumes  of  miscellaneous 
character,  but  no  other  teaching  accessories.  Dental,  pharmacy,  and  medical  stu- 
dents mingle  in  the  same  classes. 

Clinical  facilities :  The  school  has  access  to  two  small  hospitals,  whose  work  is  almost 

four-fifths  surgical.  The  dispensary  has  a  large  attendance. 
Date  of  visit:  March,  1909. 

(5)  HAHNEMANN  MEDICAL  COLLEGE  AND  HOSPITAL.  Organized  1848.  An  independent 
institution. 

Entrance  requirement:  Less  than  a  four-year  high  school  education, — probably  much 
less,  for  most  of  the  credentials  were  passed  on  by  the  secretary. 

Attendance:  182,  61  per  cent  from  Pennsylvania. 

Teaching  staff:  72,  of  whom  27  are  professors,  45  of  other  grade.  One  teacher  devotes 
his  entire  time  to  the  school. 

Resources  available  for  maintenance:  Fees,  amounting  to  $18,500. 


296  MEDICAL  EDUCATION 

Laboratory  facilities:  The  school  possesses  an  ordinary  laboratory  for  general  chem- 
istry; a  second,  with  slight  equipment,  for  histology  and  physiology ;  and  another, 
fairly  equipped,  for  pathology  and  bacteriology.  The  dissecting-room  is  clean  and 
odorless.  Both  regular  and  homeopathic  pharmacy  are  taught.  There  is  a  large 
and  very  well  kept  museum. 

Clinical  facilities:  The  school  is  connected  with  the  Hahnemann  Hospital,  containing 
some  150  beds;  but  no  ward  clinics  are  held.  Patients  are  wheeled  into  the  amphi- 
theater. Students  have  no  access  to  the  clinical  laboratory. 

The  dispensary  has  a  large  attendance,  and  there  only,  for  the  most,  the  student 
comes  into  close  contact  with  patients. 

Dot*  of  visit:  March,  1909. 

(6)  WOMAN'S  MEDICAL  COLLEGE  OF  PENNSYLVANIA.  Organized  1850.  An  independent 
institution. 

Entrance  requirement:  A  high  school  education  or  its  equivalent. 
Attendance:  125. 

Teaching  staff:  52,  of  whom  25  are  professors,  27  of  other  grade.  One  teacher  de- 
votes entire  time  to  the  schools;  several  others  teach  laboratory  subjects  elsewhere 
as  well. 

Resources  available  for  maintenance:  Fees,  amounting  to  $15,480,  and  income  from 
endowments,  amounting  to  $13,820. 

Laboratory  facilities :  Simply,  but  intelligently,  equipped  and  conscientiously  used 
laboratories  are  provided  for  physiology,  bacteriology  and  pathology,  histology 
and  embryology,  chemistry,  pharmacy,  and  anatomy.  There  is  striking  evidence 
of  a  genuine  effort  to  do  the  best  possible  with  limited  resources.  There  are  a  use- 
ful library  and  a  good  museum. 

Clinical  facilities  .-The  school  is  now  building  a  new  hospital,  part  of  which  is  already 
in  use.  This,  with  a  temporary  building,  accommodates  27  beds.  There  is,  besides 
a  maternity  of  16  beds,  and  an  out-patient  obstetrical  service.  Ward  work,  with 
assignment  of  individual  cases,  is  regularly  carried  on.  Supplementary  opportuni- 
ties are  obtained  at  several  other  institutions.  There  is  a  fair  dispensary  service. 

Dot*  of  visit:  March,  1909. 

(7)  PHILADELPHIA  COLLEGE  AND  INFIRMARY  OF  OSTEOPATHY.  Established  1898.  An 
independent  institution. 

Entrance  requirement:  Nominal. 

Attendance:  126. 

Teaching  stajf:  18,  of  whom  11  are  professors,  7  of  other  grade. 


PENNSYLVANIA  297 

Resources  available  for  maintenance:  Fees,  amounting  to  $18,900  (estimated). 

Laboratory  facilities :  These  are  utterly  wretched.  They  comprise  a  laboratory  for 
histology,  in  which  a  small  centrifuge  is  the  only  visible  object  of  interest;  a  small 
laboratory  for  elementary  chemistry  in  a  dark  cellar;  and  an  intolerably  foul  dissect- 
ing-room in  a  dark  building,  once  a  stable.  If  there  is  any  provision  for  pathology, 
physiology,  or  bacteriology,  any  books,  or  museum,  or  other  teaching  accessories 
except  a  few  crude  drawings,  a  model,  and  a  skeleton,  all  was  successfully  concealed. 
Three  separate  class-rooms  are  provided, — containing  necessary  furniture  only. 

Clinical  facilities:  The  infirmary,  the  address  of  which  is  not  given  in  the  catalogue, 
is  some  blocks  distant;  it  contains  three  beds  and  has,  it  is  claimed,  200  patients 
who  come  twice  or  thrice  weekly  for  treatment.  The  catalogue  announces  that  its 
students  have  the  "privilege  of  witnessing  operations  at  the  University  Hospital, 
Jefferson  Hospital,  etc."  This  is  not  the  case.  These  students  are  intruders,  with- 
out rights  or  privileges  of  any  description  whatsoever. 

Date  of  visit :  January,  1910. 

PITTSBURGH:  Population,  570,065. 

(8)  UNIVERSITY  OF  PITTSBURGH,  MEDICAL  DEPARTMENT.  Organized  1886;  affiliated  with 
the  University  of  Pittsburgh  in  1892,  it  became  an  organic  department  thereof 
in  1909. 

Entrance  requirement:  Four-year  high  school  education  or  its  equivalent. 
Attendance:  315. 

Teaching  staff:  103,  of  whom  43  are  professors,  60  of  other  grade.  Five  instructors 
give  their  entire  time  to  the  school.  There  is  one  research  assistant. 

Resources  available  for  maintenance:  Fees,  amounting  to  $48,500. 

Laboratory  facilities :  The  school  has  within  a  year  undergone  a  complete  transfor- 
mation. A  more  thorough  piece  of  house-cleaning  within  so  short  a  period  is  hardly 
credible.  A  year  ago,  before  the  University  of  Pittsburgh  obtained  control,  the 
so-called  laboratories  were  dirty  and  disorderly  beyond  description.  Since  the  pre- 
sent management  took  hold  last  fall,  the  admission  of  students  has  been  much 
more  carefully  supervised ;  the  building  has  been  put  in  excellent  condition ;  labo- 
ratories for  chemistry,  physiology,  bacteriology,  and  pathology  have  been  remod- 
eled and  equipped  with  modern  apparatus  for  both  teaching  and  research;  foreign 
and  domestic  periodicals  have  been  subscribed  for;  a  study-room  in  good  order  has 
been  instituted  in  place  of  the  lounging-room  where  last  year  "  four  dozen  wooden 
chairs  were  broken."  Whole-time  instructors  of  modern  training  and  ideals  have 
been  secured.  This  is  the  more  remarkable,  as  only  fees  have  been  available.  De- 
spite the  necessary  defects  of  schools  relying  wholly  on  fees,  the  experience  of  this 


298  MEDICAL  EDUCATION 

institution  confirms  our  contention  that  the  conscientious  and  intelligent  use  of 
fees  would  alone  greatly  improve  existing  conditions  in  most  schools. 
A  new  building  is  in  process  of  erection. 

Clinical  facilities:  The  school  has  access  to  several  hospitals  in  which  an  abundance 
of  material  is  available,  subject,  however,  to  the  usual  limitations.  The  clinical 
instruction  is  therefore  here,  as  generally  elsewhere,  put  together  of  disconnected 
parts.  This  does  not,  however,  apply  to  obstetrics;  for  the  school  controls  a  ma- 
ternity hospital  of  34  beds,  which,  quite  slovenly  a  year  ago,  has  also  been  trans- 
formed in  the  last  few  months.  It  is  neat,  clean,  well  managed,  and  has  been  im- 
proved by  the  addition  of  a  new  delivery-room,  sterilizing  outfit,  etc.  It  is  in  charge 
of  a  resident  obstetrician  of  modern  training. 

The  dispensary  has  been  similarly  reorganized.  A  permanent  nurse  has  been 
installed.  Records  are  now  in  order;  the  rooms  and  equipment  are  attractive  and, 
in  the  main,  adequate. 

Date  ofvuit:  February,  1910. 

(9)  THE  PHILADELPHIA  POLYCLINIC.  A  postgraduate  independent  school. 
Entrance  requirement  .•'The  M.D.  degree. 

Attendance:  Short  courses,  ranging  from  six  weeks  to  six  months  in  length,  are  given, 
the  attendance  varying  from  time  to  time.  The  annual  attendance  is  perhaps  150. 

Teaching  staff':  129,  of  whom  29  are  professors,  100  of  other  grade. 
Resources  available  for  maintenance:  Fees  and  donations. 

Laboratory  facilities :  The  school  has  what  no  other  postgraduate  school  in  the  coun- 
try possesses, — a  laboratory  building  in  which  its  classes  in  clinical  microscopy, 
operative  surgery,  etc.,  are  conducted.  The  instruction  is  of  a  practical  character, 
aiming  to  meet  the  needs  of  physicians  whose  training  has  been  defective.  No  ani- 
mals are  used  and  no  active  research  is  in  progress.  There  are  few  books  and  peri- 
odicals in  reach. 

Clinical  facilities:  The  Polyclinic  Hospital,  an  excellently  conducted  institution,  con- 
tains 81  beds  available  for  teaching  purposes.  Ward  classes  receive  demonstrative 
instruction. 

The  present  dispensary  consists  of  a  suite  of  rooms  quite  inadequate  to  the 
amount  of  material  to  be  handled.  A  new  building  is  in  process  of  erection. 

Date  ofvitit:  February,  1910. 

General  Considerations 

MEDICAL  education  in  the  state  of  Pennsylvania  presents  no  unusual  problems  from  the 
standpoint  of  theory.  It  is  easy  enough  to  decide  what  ought  to  happen.  From  a  practi- 
cal point  of  view,  however,  the  situation  is  exceedingly  difficult.  The  medical  schools 


PENNSYLVANIA  299 

are  in  some  respects  strong  institutions ;  moreover,  education,  philanthropy,  and  pol- 
itics have  become  so  interwoven  that  they  make  a  combination  too  intricate  to  be 
readily  dissolved. 

The  state  is  without  an  educational  system ;  and  the  legislature  has  recently  re- 
fused to  pass  a  bill  aiming  to  organize  the  common,  secondary,  and  normal  schools 
of  the  state.  Ordinary  educational  values  are  therefore  still  obscure  and  confused. 
Though  the  last  legislature  improved  the  law  regulating  medical  education  to  the 
extent  of  making  a  four-year  high  school  course  or  its  equivalent  the  legal  minimum, 
the  educational  disorganization  of  the  state  makes  its  enforcement  problematical. 

There  is  still  another  source  of  apprehension  on  this  score.  The  real  standard  de- 
pends on  who  evaluates  the  "equivalent.11  The  agents  to  whom  this  function  has  been 
officially  delegated  in  the  past  have  conceded  much  to  the  wishes — real  or  supposed 
—  of  the  schools.  The  Pittsburgh  representative  has  been  extremely  lax;  his  "equiva- 
lent" to  the  four-year  high  school  education  has  not  been  equal  to  a  two-year  high 
school  education.  The  present  incumbent  at  Philadelphia  is  newly  appointed;  con- 
ditions described  in  the  text  refer  to  previous  years.  Finally,  some  of  the  schools  have 
been  using  their  own  judgment  in  dealing  with  credentials,  referring  only  such  as 
they  did  not  accept  themselves.  It  is  impossible  to  ascertain  how  those  referred  were 
distinguished  from  those  accepted  in  the  medical  school  office. 

If,  now,  a  genuine  four-year  high  school  standard  is  enforced,  out  of  the  eight 
undergraduate  schools  in  the  state  only  two  will  avoid  very  serious  damage:  the  Uni- 
versity of  Pennsylvania  and  the  Jefferson  Medical  College,  the  former  already  beyond 
the  standard  in  question,  the  latter  probably  strong  enough  to  stand  the  shrinkage 
which  would  result, — for  a  large  part  of  its  enrolment  now  meets  the  requirement. 
The  University  of  Pittsburgh  is  fully  alive  to  the  necessity  of  procuring  endowment 
in  order  to  meet  the  inevitable  deficit,  and  will  stand  or  fall  on  that  issue.  The  other 
five  schools  have  no  future;  their  enrolment  is  so  largely  the  make-believe  equivalent 
that  enforcement  of  a  real  four-year  high  school  standard  will  seriously  threaten 
their  existence  even  at  their  present  level  of  efficiency ;  progress  would  be  altogether 
impossible. 

The  situation  so  far  simplified  by  an  actual  entrance  standard,  another  topic  presses 
for  consideration.  The  state  of  Pennsylvania  has  for  years  been  engaged  in  distribut- 
ing large  sums  to  private  and  semi-private  charities.  These  largesses  have  enabled 
several  of  the  Philadelphia  schools  to  build  and  partly  to  maintain  their  own  hospi- 
tals. That  this  policy  is  thoroughly  objectionable  and  demoralizing  is  beyond  dis- 
pute. The  state  has  neither  right  nor  business  to  make  presents  to  private  corpora- 
tions that  it  can  neither  regulate  nor  control.  And  the  level  of  civic  life  in  Pennsyl- 
vania has  been  greatly  lowered  by  the  log-rolling  and  favoritism  that  the  possibilities 
of  "  pulP  have  created.  One  would  be  perhaps  not  over-sanguine  to  expect  that  the 
bounty  and  subsidy  system  will  one  day  be  replaced  by  strict  payment  for  services 
rendered,  —  so  strict,  that  the  hospitals  will,  as  in  New  York,  lose  rather  than  gain 


300  MEDICAL  EDUCATION 

by  the  operation.  The  unendowed  medical  schools  of  the  state  cannot  survive  such  a 
wholesome  treatment  of  the  state's  philanthropic  obligations.  The  extension  of  their 
hospitals  would  be  prohibited;  even  their  maintenance  would  be  imperiled. 

It  is  thus  clear  that  a  reasonable — not  a  high — standard  of  admission  and  a 
righteous  public  policy  in  dealing  with  charities  would  soon  reduce  the  schools  of 
the  state  to  two, — the  University  of  Pittsburgh,  provided  it  secures  endowment,  and 
the  University  of  Pennsylvania,  whose  resources  available  for  medical  education  would 
also  require  to  be  increased.  Fortunate  indeed  would  it  be,  if  broad  views  might 
bring  about  this  increase  in  part  through  consolidation  of  the  three  large  schools 
of  Philadelphia,  one  or  two  of  the  three  being  liquidated  as  a  means  of  liberating  a 
considerable  sum,  applicable  thenceforth  to  the  development  of  the  single  surviving 
school.  Into  such  a  scheme — inevitable,  in  any  case,  unless  the  independent  schools 
accomplish  the  heretofore  impossible  task  of  procuring  endowment — the  Polyclinic 
would  easily  falL  The  day  of  independent  and  elementary  postgraduate  instruction  is 
rapidly  passing;  the  postgraduate  school  of  the  future  will  crown  a  substantial  under- 
graduate school  of  medicine.  The  outcome  here  suggested  can  be  averted  only  if  the 
independent  schools  secure  endowment, — for  which  there  is  no  precedent  in  America, 
— or  if  some  university  outside  Philadelphia  form  an  alliance  there.  There  is  just  now 
no  academic  institution  in  the  state  whose  resources  would  warrant  this  step.  What- 
ever these  medical  schools  now  offer,  they  would,  singly  or  combined,  shortly  prove 
a  drain  on  any  university  endeavoring  to  apply  to  medicine  the  standards  and  ideals 
cultivated  in  its  other  departments.  Moreover,  as  two  schools — one  at  Pittsburgh, 
the  other  at  Philadelphia — can  supply  the  state  with  physicians,  no  other  university 
is  justified  in  entering  the  field  unless  its  resources,  free  to  be  applied  to  medicine,  are 
sufficient  to  insure  as  a  consequence  a  real  advance  in  medical  knowledge  and  practice. 


SOUTH  CAROLINA 

Population,  1,510,566.  Number  of  physicians,  1141.  Ratio  1:  1324.1 
Number  of  medical  schools,  1. 

CHARLESTON:  Population,  56,659. 

MEDICAL  COLLEGE  OF  THE  STATE  OF  SOUTH  CAROLINA.  Founded  1823.  An  independent 
institution. 

Entrance  requirement :  Nominal. 
Attendance:  213. 

Teaching  staff:  34,  of  whom  11  are  professors,  23  of  other  grade.  There  are  no  whole- 
time  teachers. 

1  Folk's  statistics  make  the  ratio  1 :  1168. 


SOUTH  DAKOTA  301 

Resources  available  for  maintenance:  Fees,  amounting  to  SI  9,447  (estimated). 

Laboratory  facilities :  Comprise  very  meager  equipment  for  elementary  chemistry, 
pharmacy,  and  anatomy — the  dissecting-room  in  bad  condition.  The  instructor  in 
pathology  and  bacteriology  has  a  fair  private  laboratory,  to  which  students  have 
no  access ;  student  work  in  those  subjects  is  mostly  confined  to  looking  through 
the  microscope  at  slides  that  he  prepares.  There  is  no  museum,  except  old  papier- 
mache  and  wax  models,  no  library,  except  some  antiquated  publications.  It  is  with- 
out other  teaching  aids. 

Clinical  facilities:  The  school  has  access  to  the  Roper  Hospital,  an  unusually  at- 
tractive institution  of  about  200  beds  a  mile  distant.  There  were  80  patients  at 
the  time  of  the  visit.  Complaint  is  made  that  it  is  difficult  to  induce  graduates  to 
serve  as  internes.  Obstetrical  work  is  rare. 

There  is  no  school  or  other  organized  dispensary. 

Date  of  visit:  February,  1909. 

SOUTH  DAKOTA 

Population,  498,077.  Number  of  physicians,  607.  Ratio,  1:  821. 
Number  of  medical  schools,  1. 

VERMILION:  Population,  2183. 

UNIVERSITY  OF  SOUTH  DAKOTA  COLLEGE  OF  MEDICINE.  Organized  1907.  A  half-school. 
An  organic  department  of  the  state  university. 

Entrance  requirement:  2  years  of  college  work. 
Attendance:  7. 

Teaching  staff:  5  professors  and  5  instructors,  who  take  part  in  the  work  of  the  de- 
partment. 

Resources  available  for  maintenance:  The  department  shares  in  the  general  funds  of 
the  university.  No  separate  budget  is  prepared.  Fees  amount  to  $660. 

Laboratory  facilities :  The  necessary  equipment  is  at  hand  for  painstaking  routine 
instruction  in  the  laboratory  branches.  A  library  and  museum  have  been  started. 
Date  of  visit:  November,  1909. 

General  Considerations 

THE  two  Dakotas  have  taken  time  by  the  forelock:, before  any  vested  proprietary  in- 
terest could  be  created,  they  have  fixed  the  state  practice  requirement  at  two  years 
of  college  work,  thus  fortifying  the  medical  department  of  the  state  university.  The 
state,  though  thinly  settled,  is  prosperous,  and  no  anxiety  is  felt  that  the  high  stan- 


302  MEDICAL  EDUCATION 

dard  will  deplete  the  medical  profession  of  the  state.  On  the  contrary,  it  has  been 
adopted  as  a  means  of  protecting  a  people  already  supporting  twice  as  many  doctors 
as  it  needs. 

Though  the  students  are  few,  the  present  provision  for  their  teachers  is  on  too 
unpretentious  a  scale.  Unfortunately,  like  all  the  western  states,  South  Dakota  is 
already  scattering  its  financial  resources  among  half  a  dozen  competing  state  institu- 
tions. Of  its  seven  tax-supported  institutions  of  higher  grade,  three  give  the  A.B. 
degree  and  the  others  desire  to  do  so.  It  will  prove  decidedly  unfortunate  if  these 
institutions  are  not  in  their  infancy  coordinated,  so  as  to  form  a  genuine  system 
rather  than  a  number  of  separate,  warring  units.  A  population  of  half  a  million  in 
a  new  country  will  do  well  to  sustain  one  substantial  state  college  with  departments 
of  law,  medicine,  etc.  It  can  do  that  only  by  concentrating  its  outlay. 


TENNESSEE 

Population,  2,248,404.  Number  of  physicians,  3303.  Ratio,  1 :  681. 
Number  of  medical  schools,  9. 

CHATTANOOGA:  Population,  34,773. 

(1)  CHATTANOOGA  MEDICAL  COLLEGE.  Organized  1889.  The  medical  department  of 
the  University  of  Chattanooga. 

Entrance  requirement:  Nominal. 

Attendance:  112. 

Teaching  staff":  25,  of  whom  11  are  professors,  14  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $4290. 

Laboratory  facilities:  The  school  occupies  a  small  building,  externally  attractive;  the 
interior,  dirty  and  disorderly,  is  almost  bare,  except  for  a  fair  chemical  laboratory 
in  good  condition.  The  dissecting-room  contains  two  tables;  the  single  room 
assigned  to  histology,  pathology,  and  bacteriology  contains  a  few  old  specimens, 
mostly  unlabeled,  and  one  oil-immersion  microscope.  The  instructor  explained  that 
they  "study  only  non-pathogenic  microbes;  students  do  not  handle  the  patho- 
genic." There  is  nothing  further  in  the  way  of  laboratory  outfit ;  no  museum,  books, 
charts,  models,  etc. 

Clinical  facilities :  Amphitheater  clinics  are  held  at  the  Erlanger  Hospital,  which 
averages  about  50  free  patients.  Students  may  not  enter  the  wards.  Perhaps  ten 
obstetrical  cases  annually  are  obtainable,  students  being  "summoned," — just  how 
is  not  clear.  The  students  see  no  post-mortems,  no  contagious  diseases,  do  no  blood 


TENNESSEE  303 

or  urine  work,  and  do  not  always  own  their  own  text-books.  They  use  quiz-com- 
pends  instead. 

There  is  no  dispensary. 

This  is  a  typical  example  of  the  schools  that  claim  to  exist  for  the  sake  of  the  poor 
boy  and  the  back  country. 

Date  of  visit :  January,  1909. 

KNOXVILLE :  Population,  38,328. 

(2)  TENNESSEE  MEDICAL  COLLEGE.  Organized  1889.  A  stock  company;  nominally  the 
medical  department  of  Lincoln  Memorial  University. 

Entrance  requirement:  Nominal. 

Attendance:  82,  70  per  cent  from  Tennessee. 

Teaching  staff:  31 ,  of  whom  26  are  professors,  5  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $4994. 

Laboratory  facilities :  The  school  building  is  externally  attractive;  within,  dirty.  In 
the  basement  is  a  small  laboratory  for  inorganic  chemistry.  A  few  microscopes,  a 
microtome,  and  some  sterilizing  apparatus — no  cultures  or  pathological  specimens 
were  visible — constitute  the  laboratory  for  pathology,  bacteriology,  and  histology. 
The  dissecting-room  is  ordinary ;  there  are  no  books,  museum,  charts,  etc. 

Clinical  facilities :  The  school  adjoins  a  neat  hospital,  recently  constructed,  which 
proves,  however,  to  be  simply  the  private  hospital  of  the  faculty  for  which  student 
fees  help  to  pay.  It  has  an  average  of  40  patients,  with  no  free  wards.  Five  clinics 
weekly  are  scheduled,  but  it  is  admitted  that  "they  are  not  always  held."  Practi- 
cally, students  "are  called"  when  a  case  happens  along  which  the  doctor  can  ar- 
range to  have  them  see.  Obstetrical  instruction  is  limited  "to  a  few  deliveries 
before  the  class." 

There  is  no  dispensary. 

Date  of  vitit :  January,  1909. 

(3)  KNOXVILLE  MEDICAL  COLLEGE.  Colored.  Established  1900.  An  independent  insti- 
tution. 

Entrance  requirement:  Nominal. 

Attendance:  23. 

Teaching  staff":  11,  of  whom  9  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $1020  (estimated). 

Laboratory  facilities :  None.  The  school  occupies  a  floor  above  an  undertaker's  esta- 
blishment. 


304  MEDICAL  EDUCATION 

Clinical  facilities:  None.  It  was  stated  by  a  student  that  twice  between  October  1  and 
January  28  "a  few  students  were  taken  to  the  Knoxville  College  Hospital."" 
There  is  no  dispensary. 

The  catalogue  of  this  school  is  a  tissue  of  misrepresentations  from  cover  to  cover. 
Date  ofvifit :  January,  1909. 

MEMPHIS:  Population,  140,145. 

(4)  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  1906.  A  stock  company,  now 
calling  itself  the  medical  department  of  the  University  of  Memphis,  a  fictitious 
affair. 

Entrance  requirement:  None.  "Accept  students  and  try  them  out." 
Attendance:  77. 

Teaching  staff:  47,  of  whom  22  are  professors,  25  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  $7400  (estimated). 

Laboratory  facilities :  The  school  occupies  an  excellent  building,  recently  erected,  fees 
being  largely  consumed  in  helping  to  pay  for  it.  The  dissecting-room  is  of  modern 
design,  consisting  of  small  rooms  with  hot  and  cold  water;  but  the  work  was  con- 
ducted on  antiquated  lines,  cadavers  being  in  wretched  condition.  The  chemical 
laboratory  is  good  and  quite  adequate  to  instruction  in  elementary  chemistry. 
Equipment  for  pathology  and  bacteriology  is  less  than  fair;  for  physiology,  prac- 
tically nothing.  There  are  few  books,  no  museum,  charts,  etc. 

Clinical  facilities:  The  schedule  shows  seven  one-hour  clinics  (5  in  surgery,  2  in  medi- 
cine) per  week  at  the  City  Hospital  during  one-half  of  the  school  year.  At  the  date 
of  the  visit,  perhaps  40  beds  were  thus  accessible.  Students  "look  on"  at  the  ob- 
stetrical cases. 

A  suite  of  rooms  in  the  college  building  is  set  aside  for  a  dispensary. 

Date  of  visit:  November,  1909. 

(5)  MEMPHIS  HOSPITAL  MEDICAL  COLLEGE.  Organized  1880.  A  stock  company. 
Entrance  requirement:  Nominal. 

Attendance:  442. 

Teaching  staff":  35,  of  whom  12  are  professors,  23  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $34,600  (estimated).  The 
condition  of  the  school  laboratories  shows  what  becomes  of  this  sum. 

Laboratory  facilities :  The  school  occupies  an  excellent  building,  heavily  mortgaged. 
It  is  new  and  well  kept.  The  chemical  laboratory  is  good  and  adequate  to  ele- 
mentary chemistry.  An  excellent  room  is  assigned  to  dissecting,  but  the  cadavers 


TENNESSEE  305 

are  putrid.  One  laboratory,  with  slight  equipment  and  little  material,  answers  for 
all  microscopic  work.  It  is  obvious  that  large  classes  have  paid  in  considerable 
sums  that  have  been  used  to  pay  for  an  expensive  building,  not  to  provide  even 
fair  teaching  facilities.  The  course  of  instruction  is  not  graded. 

Clinical  facilities :  The  schedule  shows  nine  one-hour  clinics  a  week  at  the  City  Hospi- 
tal, where  the  available  material  is  divided  between  the  two  schools.  At  the  date 
of  the  visit,  perhaps  40  beds  were  thus  accessible  to  each.  Students  "look  on"  at 
the  obstetrical  cases.  The  course  of  instruction  is  not  graded ;  the  amount  of  mate- 
rial is  absurdly  inadequate  for  the  huge  classes. 

There  is  a  dispensary  in  the  school  building.  Its  equipment  is  slight;  there  are 
no  systematic  records.  The  amount  of  material  cannot  possibly  suffice  for  the 
student  body;  and  there  is  nothing  to  indicate  effective  use,  as  far  as  it  goes. 

Dale  of  visit:  November,  1909. 

(6)  UNIVERSITY  OF  WEST  TENNESSEE,  MEDICAL  DEPARTMENT.  Colored.  Organized 
1900. 

Entrance  requirement:  Nominal. 

Attendance:  40. 

Teaching  staff:  14,  all  of  whom  are  professors. 

Resources  available  for  maintenance:  Fees,  amounting  to  $2000  (estimated). 

Laboratory  facilities:  There  is  meager  equipment  for  chemistry,  pharmacy,  and  mi- 
croscopy. Otherwise  the  rooms  are  bare. 

Clinical  facilities:  The  students  have  access  to  eight  or  ten  beds,  twice  weekly,  in  a 
small  hospital  close  by. 

There  is  a  dispensary,  without  records,  in  the  school  building. 
Date  of  visit:  November,  1909. 

NASHVILLE:  Population,  107,076. 

(7)  VANDERBILT  UNIVERSITY  MEDICAL  DEPARTMENT.  Established  1874.  An  organic 
department  of  the  university. 

Entrance  requirement:  Less  than  high  school  graduation,  though  a  fair  proportion 
of  the  students  have  had  some  college  work. 

Attendance:  200. 

Teaching  staff:  40,  of  whom  17  are  professors,  23  of  other  grade.  The  dean  of  the 
school  is  the  professor  of  chemistry  in  the  academic  department — an  undesirable 
arrangement  at  a  time  when  medical  education  is  so  rapidly  changing  form.  No 
instructor  devotes  entire  time  to  the  medical  department. 


806  MEDICAL  EDUCATION 

Resources  available  for  maintenance:  Fees,  amounting  to  $26,250.  This  sum,  adequate 
to  provide  fair  laboratory  instruction,  is  not  devoted  to  education  alone.  The 
medical  department,  although  organically  part  of  the  university,  is  under  contract 
to  wipe  out  with  its  fees  the  cost  of  the  building  it  occupies,  and  meanwhile  it  pays 
the  university  interest  at  six  per  cent  on  the  unpaid  balance. 

Laboratory  facilities :  The  school  possesses  satisfactory  laboratories  for  pathology, 
bacteriology,  and  histology,  and  an  energetic  instructor  has  charge  of  them.  A 
creditable  beginning  has  been  made  in  experimental  physiology.  Chemistry  is  well 
provided  by  the  university.  Anatomy  is  bad — the  work  being  conducted  on  anti- 
quated lines  in  a  foul  dissecting-room.  There  is  a  useful  museum  and  a  fair  library. 

Clinical  facilities :  The  school  has  converted  the  basement  of  its  own  building  into  a 
ward  of  35  beds;  and  has  access  to  the  City  Hospital  (65  beds)  besides.  The 
amount  of  material  thus  available  is  too  restricted. 
There  is  a  dispensary  with  a  fair  attendance. 

Date  ofvifit:  January,  1909. 

(8)  UNIVERSITIES  OF  NASHVILLE  AND  TENNESSEE  MEDICAL  DEPARTMENT.  A  combina- 
tion under  limited  contract,  formed  in  1909,  expiring  1912.  One  of  the  two  in- 
stitutions represented  is  the  State  University  of  Tennessee  (Knoxville),  the  other 
the  University  of  Nashville, — a  university  in  name  only. 

Entrance  requirement:  Less  than  high  school  graduation. 
Attendance:  207. 

Teaching  staff:  55,  of  whom  26  are  professors,  29  of  other  grade.  The  distribution 
of  chairs  is  significant :  there  are  four  professors  of  medicine,  four  professors  of 
surgery  (not  including  gynecology),  and  one  whole-time  teacher. 

Resources  available  for  maintenance:  Fees,  amounting  to  $26,000  (estimated),  and 
subscriptions  from  the  two  universities,  amounting  to  $8100  in  cash.  Of  the  two 
universities,  the  University  of  Tennessee  is  supported  by  legislative  appropria- 
tion; the  University  of  Nashville  has  an  endowment  of  $60,000,  yielding  $3600 
annually. 

Laboratory  facilities:  These  comprise  a  poor  laboratory  for  elementary  chemistry, 
an  outfit,  in  part  new,  for  bacteriology,  pathology,  histology,  and  physiology,  and 
a  poorly  kept  dissecting-room.  There  is  a  small  museum. 

Clinical  facilities :  The  building  formerly  used  by  the  medical  department  of  the  Uni- 
versity of  Tennessee  has  been  converted  into  a  hospital  with  a  capacity  of  70  beds. 
In  view  of  the  brief  period  that  has  elapsed  since  the  merger,  this  improvement 
in  clinical  resources  is  most  commendable,  for  the  hospital  is  completely  controlled 
by  the  school.  The  school  has  access  to  the  City  Hospital  besides. 


TENNESSEE  307 

The  first  floor  of  the  college  hospital  building  is  used  as  a  dispensary.  Though 
its  equipment  is  still  slight,  it  represents  a  great  advance  over  the  conditions  that 
preceded. 

Date  of  visit :  January,  1909. 

(9)  MEHARRY  MEDICAL  COLLEGE.  Colored.  Organized  1876.  The  medical  department 
of  Walden  University. 

Entrance  requirement:  Less  than  a  four-year  high  school  education. 

Attendance:  275. 

Teaching-  staff1:  26,  of  whom  12  are  professors,  14  of  other  grade. 

Resources  available  for  maintenance:  $23,946,  representing  income  from  endowment 
of  $35,000,  subscription  from  the  Freedman's  Aid  Society,  and  fees,  the  last  item 
being  $20,310. 

Laboratory  facilities :  The  school  possesses  fair  laboratories  for  chemistry  and  physi- 
ology and  highly  creditable  laboratories  for  bacteriology,  histology,  and  patho- 
logy, the  outfit  including  animals,  microscopes,  microtome,  and  pathological  ma- 
terial in  excellent  order.  A  separate  frame  building,  well  kept,  is  devoted  to  anatomy. 
The  equipment  and  general  conditions  reflect  great  credit  on  the  zeal  and  intelli- 
gence of  those  in  charge  of  the  school  and  its  several  departments. 

Clinicalfacilities :  These  are  restricted.  The  school  has  access  to  Mercy  Hospital,  32  beds. 

Date  of  visit :  January,  1909. 

General  Considerations 

THE  state  of  Tennessee  protects  at  this  date  more  low-grade  medical  schools  than 
any  other  southern  state.  It  would  be  unfair  and  futile  to  criticize  this  situation 
without  full  recognition  of  local  conditions.  A  standpoint  that  is  entirely  in  order 
in  dealing  with  Cincinnati,  Chicago,  or  St.  Louis  is  here  irrelevant.  The  ideals  held 
up  must  indeed  be  the  same;  but  their  attainment  is  much  further  in  the  future. 
The  amount  of  money  available  for  medical  education  is  small ;  the  preliminary  re- 
quirement must  be  relatively  low.  Practically  all  that  can  be  asked  of  Tennessee  is 
that  it  should  do  the  best  possible  under  the  circumstances. 

This  it  does  not  do.  The  six  white  schools  value  their  separate  survival  beyond  all 
other  considerations.  A  single  school  could  furnish  all  the  doctors  the  state  needs 
and  do  something  to  supply  the  needs  of  adjoining  states  as  well.  Low  as  the  en- 
trance standard  must  be,  it  has  been  made  lower  in  order  to  gather  in  students  for  six 
schools  where  one  would  suffice.  The  medical  schools  solicit  and  accept  students  who 
have  not  yet  made  the  best  of  the  limited  educational  opportunities  their  homes  pro- 
vide; and  to  this  extent,  not  only  injure  the  public  health,  but  depress  and  demo- 
ralize the  general  educational  situation. 


308  MEDICAL  EDUCATION 

The  same  is  true  in  reference  to  laboratories  and  clinics.  However  small  the  sums 
applicable  to  building  and  equipping  laboratories,  conditions  are  needlessly  aggra- 
vated when  six  plants  are  equipped  instead  of  one.  Fees  that  ought  now  to  be  used 
in  providing  better  teaching  are  still  paying  for  expensive  buildings  in  Memphis  and 
Nashville.  The  city  hospitals  of  both  places,  small  at  best,  are  divided  between  two 
schools,  though  they  do  not  furnish  enough  material  for  one. 

Those  who  deal  with  medical  education  in  Tennessee  are  therefore  making  the 
worst,  not  the  best,  of  their  limited  possibilities.  Their  medical  schools,  treated  on 
their  merits,  would  speedily  reduce  to  one :  the  utterly  wretched  establishments  at 
Chattanooga  and  Knoxville  would  be  wiped  out;  the  more  showy,  but  quite  mer- 
cenary, concerns  at  Memphis  would  be  liquidated.  The  University  of  Tennessee,  with 
an  annual  income  that  does  not  as  yet  suffice  for  the  legitimate  needs  of  its  own  plant 
at  Knoxville,  should  abandon  for  the  present  the  effort  to  develop  at  Nashville  a 
school  that  it  can  neither  control  nor  support.  The  time  may  come  when  there  will  be 
a  call  for  the  state  university  to  enter  the  field.  But  that  time  is  not  now.  For  the 
present  it  is  dividing  its  own  forces  and  hindering  the  most  effective  use  of  such  re- 
sources as  Nashville  affords.  The  whole  field  is  strangely  confused :  Lincoln  Memorial 
University  (which  is  an  industrial  school,  not  a  university)  at  Cumberland  Gap 
shelters  a  medical  school  at  Knoxville;  the  University  of  Tennessee  at  Knoxville 
shelters  an  entirely  superfluous  school  at  Nashville. 

If  our  analysis  is  correct,  the  institution  to  which  the  responsibility  for  medical 
education  in  Tennessee  should  just  now  be  left  is  Vanderbilt  University;  for  it  is 
the  only  institution  in  position  at  this  juncture  to  deal  with  the  subject  effectively. 
This  does  not  mean  that  Vanderbilt  has  now  any  large  sums  of  money  available  or 
that  it  should  inaugurate  impossible  entrance  standards.  It  can  do  neither,  for  the 
general  situation  countenances  neither.  The  suggestion  merely  recognizes  the  facts 
that  one  school  can  do  the  work ;  that  Vanderbilt  occupies  in  Nashville  the  point  of 
vantage;  that,  in  the  public  interest,  the  field  should  be  left  to  the  institution  best 
situated  to  handle  it. 

On  the  other  hand,  any  such  arrangement  imposes  upon  Vanderbilt  a  very  distinct 
responsibility.  It  would  have  to  nurse  its  enrolment:  having  determined  just  how 
large  a  school  local  needs  require,  it  must  fix  and  enforce  the  strictest  entrance  re- 
quirement compatible  therewith.  At  the  present  time  this  standard  would  be  less  than 
four-year  high  school  graduation;  but  whatever  it  be,  if  only  it  is  real  and  definite, 
it  will  operate  to  brace  up  general  conditions.  Improved  teaching  should  compensate 
student  defects.  To  this  end,  every  effort  should  be  made  to  secure  endowment  specifi- 
cally applicable  to  the  medical  department;  in  the  interval,  fees  must  be  employed  not 
to  wipe  out  old  obligations,  however  incurred,  but  to  improve  the  school.  The  contract 
between  Vanderbilt  University  and  its  medical  department  should  be  canceled.  The 
practitioner  teachers  must  make  good  their  ambition  to  advance  medical  education 
by  being  content  with  the  indirect  advantage  accruing  from  school  connections.  If 


TEXAS  309 

the  entire  fee  income  is  used  to  equip  the  laboratories,  to  employ  full-time  teachers 
in  the  fundamental  branches,  to  fit  out  and  organize  a  good  dispensary,  there  will 
still  remain  defects  and  makeshifts  enough;  but  the  school  will  wear  a  different  as- 
pect than  is  presented  by  any  institution  in  the  state  to-day. 

Let  it  be  said  ungrudgingly  that  these  suggestions  are  offered  in  no  spirit  of 
unkindness.  The  State  University  and  Vanderbilt  have  had  their  hands  full.  They 
have  worked  valiantly  amidst  conditions  that  might  well  appal  the  strongest  hearts. 
They  deserve  no  blame  for  the  past,  provided  only  they  unselfishly  and  vigorously 
cooperate  in  forgetting  it.  In  the  last  few  years  right  courses  of  action  in  medical 
education  have  for  the  first  time  been  defined.  A  decade  hence  it  will  be  fair  to  look 
back  and  ask  whether  the  universities  of  the  state  have  followed  them. 

Of  the  three  negro  schools  in  the  state,  two  are  without  merit.  The  third — Me- 
harry — is  a  most  creditable  institution.  The  reader  is  referred  to  chapter  xiv,  "The 
Medical  Education  of  the  Negro,"  for  a  fuller  discussion  of  its  needs  and  deserts. 


TEXAS 

Population,  3,780,574.  Number  of  physicians,  5789.  Ratio,  1 : 653. 
Number  of  medical  schools,  4. 

DALLAS:  Population,  56,119. 

(1)  BAYLOR  UNIVERSITY  COLLEGE  OF  MEDICINE.  Organized  1900.  Since  1903  the  me- 
dical department  of  Baylor  University. 

Entrance  requirement :  Nominally  a  three-year  high  school  course  or  its  equivalent. 
Attendance:  53. 

Teaching  staff:  29,  of  whom  16  are  professors,  13  of  other  grade.  All  the  teachers 
are  practitioners. 

Resources  available  for  maintenance:  Fees,  amounting  to  $7735  (estimated).  The 
school  has  not  thus  far  been  assisted  by  the  university. 

Laboratory  facilities :  The  school  possesses  a  new  laboratory  adjoining  the  hospital  to 
be  noticed  below ;  but  at  the  date  of  the  visit  it  was  still  quite  bare.  The  dissecting- 
room  was  in  good  condition ;  a  fair  chemical  laboratory  and  a  meagerly  equipped 
laboratory  for  pathology  and  bacteriology  had  been  installed.  There  was  nothing 
else,  and  no  assurance  of  funds  with  which  to  provide  additional  laboratories  or 
to  maintain  those  already  in  part  provided. 

Clinical  facilities :  Adjoining  the  laboratory  building  is  a  new  hospital  of  some  200 
beds,  in  which  the  school  has  access  to  two  free  wards  containing  32  beds,  and  to 


310  MEDICAL  EDUCATION 

ail  additional  negro  ward  of  22  beds  in  a  pavilion  close  by.  There  is  no  clinical 
laboratory.  Clinical  opportunities  are  obtained  at  two  other  institutions,  but  no 
infectious  diseases  and  little  obstetrical  work  are  obtainable.  The  clinical  oppor- 
tunities are  thus  decidedly  inadequate. 

A  dispensary  is  just  beginning. 
Dale  of  visit:  November,  1909. 

(2)  SOUTHWESTERN  UNIVERSITY  MEDICAL  COLLEGE.  Organized  1908.  Nominally  the 
medical  department  of  Southwestern  University,  which  is  protected  by  contract 
against  liability  for  its  debts. 

Entrance  requirement :  Nominally  a  three-year  high  school  course  or  its  equivalent. 
Attendance:  68. 

Teaching  staff':  32,  of  whom  17  are  professors,  15  of  other  grade.  All  are  practitioners. 
Resources  available  for  maintenance:  Fees  only,  amounting  to  $7150  (estimated). 

Laboratory  facilities :  The  school  possesses  a  new  building,  externally  attractive  but 
wretchedly  kept.  It  contains  a  disorderly  and  incomplete  chemical  laboratory,  a 
small  amount  of  new  physiological  apparatus,  a  single  laboratory  fairly  well 
equipped  for  pathology  and  bacteriology,  and  an  ordinary  dissecting-room.  There 
is  a  "  reading-room  "  with  nothing  to  read.  The  lecture-rooms  are  bare,  except  for 
chairs ;  in  a  corner  of  one  of  them  is  an  abused  manikin. 

Clinical  facilities :  Amphitheater  clinics  in  surgery  are  held  once  weekly  at  an  insti- 
tution across  the  street,  where  perhaps  50  beds,  mostly  surgical,  are  accessible,  and 
one  afternoon  a  week  at  the  City  Hospital,  one  and  a  half  miles  distant.  No  in- 
fectious diseases  are  obtainable.  Neither  hospital  contains  a  clinical  laboratory. 
Clinical  opportunities  are  therefore  decidedly  inadequate. 
A  dispensary  is  just  starting. 

Date  of  visit:  November,  1909. 

FORT  WORTH:  Population,  27,096. 1 

(3)  FORT  WORTH  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1894.  A  nominal  de- 
partment of  a  local  "  university." 

Entrance  requirement :  Nominally  a  three-year  high  school  course  or  its  equivalent. 
Attendance:  100. 

Teaching" staff":  47,  of  whom  14  are  professors,  33  of  other  grade.  All  are  practitioners. 
Resources  available  for  maintenance:  Fees  only,  amounting  to  $10,500  (estimated). 
Laboratory  facilities :  These  comprise  a  dissecting-room,  ordinary  laboratories  for 
1  N"t  estimated  by  U.  S.  Census  Bureau. 


TEXAS  311 

chemistry  and  bacteriology,  and  a  single  laboratory  with  routine  outfit  for  patho- 
logy and  histology;  recent  provision  on  a  small  scale  has  been  made  for  physiology. 
The  class-rooms  are  bare  except  for  a  reflectoscope  and  a  defective  skeleton.  There 
are  a  small  museum  of  unlabeled  specimens  and  a  small  library. 

Clinical  facilities :  The  basement  of  the  school  building  makes  a  wretched  hospital  of 
50  beds,  20  of  them  free.  There  is  no  clinical  laboratory.  One  surgical  clinic  weekly 
is  held  at  a  private  hospital  two  miles  distant. 

For  the  dispensary  a  fair  attendance  is  claimed,  but  no  complete  index  is  kept. 

Date  of  visit :  November,  1909. 

GALVESTON:  Population,  37,834. 

(4)  UNIVERSITY  OF  TEXAS,  DEPARTMENT  OF  MEDICINE.  Organized  1891.  An  organic 
department  of  the  state  university. 

Entrance  requirement:  A  four-year  high  school  education,  passed  on  by  the  state 
university. 

Attendance:  206. 

Teaching  staff:  26,  of  whom  9  are  professors,  17  of  other  grade.  Three  professors  and 
seven  instructors  give  entire  time  to  the  department.  All  instructors  are  on  salary. 

Resources  available  for  maintenance :  The  department  is  carried  by  the  general  funds 
of  the  university.  Its  budget  calls  for  863,342,  of  which  $6500  are  derived  from 
fees;  the  hospital  budget  requires  $39,611  besides. 

Laboratory  facilities :  The  school  has  a  complete  series  of  admirable  teaching  lab- 
oratories, covering  anatomy,  physics,  chemistry,  physical  chemistry,  pathology, 
bacteriology,  histology,  and  embryology.  There  is  a  large  pathological  museum, 
beautifully  kept,  every  specimen  classified,  labeled,  and  indexed;  and  a  notable 
anatomical  museum  in  which  special  preparations  are  most  advantageously  ar- 
ranged for  teaching  use.  The  library  is  good  and  is  in  regular  receipt  of  foreign 
and  domestic  journals;  animals  in  abundance  are  on  hand.  Competent  helpers  are 
provided  for  each  floor.  No  effort,  however,  is  made  in  the  direction  of  research. 

Clinical  facilities :  A  university  hospital  of  155  beds  adjoins  the  laboratories.  Its  or- 
ganization is  along  sound  lines — the  service  with  a  single  chief  being  continuous, 
but  students  have  not  as  yet  been  actively  utilized  in  the  wards.  As  elevated  stan- 
dards improve  the  student  body,  this  innovation  will  become  more  feasible. 

For  lack  of  assistants,  the  dispensary  is  not  so  thoroughly  organized.  The  at- 
tendance is  fair. 

Date  of  visit:  November,  1909. 


312  MEDICAL  EDUCATION 

General  Considerations 

TEXAS  is  indubitably  a  state  destined  to  a  great  development;  its  educational  insti- 
tutions must  from  time  to  time  be  readjusted  to  take  account  of  its  expanded  needs. 
It  is  neither  wise  nor  possible  to  provide  now  for  requirements  that  will  a  genera- 
tion hence  become  imperative.  Sufficient  for  the  people  of  Texas  to-day  to  meet  in 
the  most  effective  way  possible  their  own  needs. 

There  is  now  only  one  educational  institution  in  the  state  capable  of  maintaining 
a  medical  school  whose  graduates  deserve  the  right  to  practise  among  its  inhabi- 
tants; there  is  only  one  medical  school  in  the  state  fit  to  continue  in  the  work  of 
training  physicians.  That  institution  is  the  state  university;  the  medical  school  is 
its  department  at  Galveston.  The  other  three  schools  are  without  resources,  without 
ideals,  without  facilities,  though  at  Baylor  the  conjunction  of  hospital  and  labora- 
tory might  be  made  effective  if  large  sums,  specifically  applicable  to  medical  edu- 
cation, were  at  hand, — which  is  not,  however,  the  case. 

There  is  no  indication  on  the  face  of  things  that  any  of  the  three  inferior  schools 
can  live  through  the  dry  period  to  the  opportunities  of  the  future.  Their  enrolment 
is  small;  and  the  state  is  badly  overcrowded  with  just  the  kind  of  doctor  that  they 
are  engaged  in  producing.  Should  the  loopholes  in  the  present  state  standard  be 
stopped  up,  all  three  would  quickly  disappear. 

The  course  of  the  state  university  needs  to  be  carefully  considered.  Whether  a 
college  requirement  will  soon  be  wise  is  a  question  to  be  pondered.  The  institution 
has  not  yet  exhausted  the  possibilities  of  the  high  school  standard;  its  laboratories — 
admirable  for  undergraduate  teaching — need  further  development  on  the  productive 
side;  its  hospital  must  be  enlarged;  more  effective  teaching  methods  can  be  intro- 
duced into  it;  the  dispensary  is  not  yet  effective.  It  is  worth  asking  whether  from  the 
four-year  high  school  basis  the  university  will  not  be  wise  to  get  complete  control 
of  the  field,  driving  out  the  low-grade  schools,  educating  the  people  of  the  state  to 
regard  it  as  their  main  source  of  supplies  in  the  matter  of  doctors  and  the  active  con- 
servator of  public  health,  before  endeavoring  to  push  ahead  to  a  higher  standard, 
which  may  not  be  so  well  adapted  to  local  conditions  in  a  relatively  new  country. 

Meanwhile,  to  the  outsider  it  seems  a  regrettable  mischance  that  located  the 
medical  department  away  from  the  university.  Were  it  placed  at  Austin,  it  would 
apparently  gain  in  every  way :  the  town  is  as  large,  and  various  state  institutions  there 
would  strengthen  its  clinical  opportunities;  it  would  be  easier  to  attract  and  to  hold 
outsiders  in  teaching  positions;  the  stimulus  of  the  university  would  assist  the  growth 
of  a  productive  spirit.  Whether  at  Galveston  the  school  will  ever  be  creative  is  a 
question ;  should  it  become  so,  isolation  increases  the  liability  to  slip  back  into  an 
unproductive  groove.  Perhaps  it  is  not  yet  too  late  for  the  people  of  the  state  to  con- 
centrate their  state  institutions  of  higher  learning  in  a  single  plant. 


VERMONT  313 

UTAH 

Population,  336,122.  Number  of  physicians,  359.  Ratio,  1:  936. 
Number  of  medical  schools,  1. 

SALT  LAKE  CITY :  Population,  65,464. 

UNIVERSITY  OF  UTAH,  DEPARTMENT  OF  MEDICINE.  Organized  1906.  A  half-school.  An 
organic  part  of  the  state  university. 

Entrance  requirement:  One  year  of  college  work. 
Attendance:  18. 

Teaching  staff:  6  professors  and  10  of  other  grade,  who  take  part  in  the  instruction. 
The  professors  are  all  university  teachers,  of  whom  3  give  their  entire  time  to  me- 
dical subjects. 

Resources  available  for  maintenance :  The  department  is  supported  out  of  the  general 
funds  of  the  university.  It  costs  approximately  $10,000;  its  income  in  fees  is  $1405. 

Laboratory  facilities:  Laboratories  are  adequately  equipped  for  the  routine  instruc- 
tion of  small  classes  in  anatomy,  physiology,  physiological  chemistry,  chemistry, 
histology,  pathology,  and  bacteriology.  The  spirit  is  excellent.  A  few  books,  scien- 
tific journals,  charts,  etc.,  are  at  hand ;  a  museum  has  been  begun.  More  liberal 
support,  however,  is  necessary  if  the  department  is  to  justify  its  high  entrance 
standard. 

It  is  to  be  hoped  that  whenever  clinical  instruction  is  started  in  Salt  Lake  City, 
it  may  be  only  for  the  purpose  of  completing  the  half-course  now  offered ;  in  that 
event  Utah  need  never  know  the  proprietary  medical  school. 

Date  ofvitit :  April,  1909. 

VERMONT 

Population,  353,739.  Number  of  physicians,  663.  Ratio,  1 :  534. 
Number  of  medical  schools,  1. 

BURLINGTON:  Population,  22,690. 

UNIVERSITY  OF  VERMONT  COLLEGE  OF  MEDICINE.  Organized  1822.  Now  an  organic  part 
of  the  university. 

Entrance  requirement :  Less  than  a  four-year  high  school  education. 
Attendance:  156,  42  per  cent  from  Vermont. 

Teaching  staff:  33,  of  whom  18  are  professors,  15  of  other  grade.  Thirteen  teachers 
are  non-resident,  among  them  the  professors  of  medicine,  obstetrics,  pediatrics, 


314  MEDICAL  EDUCATION 

physiology,  and  pathology.  Some  of  the  non-resident  teachers  go  to  Burlington 
weekly  ;  others  give  a  concentrated  course  covering  several  weeks.  The  entire  teach- 
ing staff  never  meets.  There  is  one  full-time  teacher, —  in  the  department  of 
anatomy. 

Resources  available  for  maintenance :  Fees,  amounting  to  $21,388.  The  state  has  lately 
appropriated  $10,000. 

Laboratory  facilities :  The  school  has  an  attractive  new  laboratory  building  adequate 
to  routine  teaching  of  anatomy,  pathology,  histology,  bacteriology,  physiology,  and 
chemistry.  No  research  is  in  progress.  There  is  no  library,  no  museum,  few  teaching 
accessories,  and  no  animals  on  the  premises. 

Clinical  facilities :  Two  hospitals  with  200  ward  beds  are  in  a  limited  way  available, 
but  the  material  is  predominantly  surgical:  medical  and  obstetrical  cases  are  rela- 
tively few.  Infectious  diseases  are  in  the  main  didactically  taught.  There  is  little 
bedside  work,  patients  being  examined  by  assigned  students  in  a  small  room  and 
subsequently  demonstrated  in  the  amphitheater.  The  combined  Senior  and  Junior 
classes  attend  a  majority  of  the  clinics  in  internal  medicine  and  general  surgery. 
The  dispensary  has  a  small  attendance. 

Date  of  visit :  May,  1909. 

[For  general  considerations  see  "New  England,"  p.  22$.\ 

VIRGINIA 

Population,  2,032,567.  Number  of  physicians,  2215.  Ratio,  1:  918. 
Number  of  medical  schools,  3. 

CHARLOTTESVILLE:  Population,  7307. 

(1)  UNIVERSITY  OF  VIRGINIA,  DEPARTMENT  OF  MEDICINE.  Organized  1827.  An  organic 
department  of  the  university. 

Entrance  requirement:  One  year  of  college  work  in  sciences. 
Attendance:  89,  53  per  cent  from  Virginia. 

Teaching  stajf:  31  teachers,  of  whom  12  are  professors,  19  of  other  grade,  take  part  in 
the  work  of  the  department.  The  laboratory  branches  are  taught  by  8  instructors 
who  give  their  entire  time  to  them. 

Resources  available  for  maintenance:  The  budget  of  the  department  calls  for  $52,195, 
including  hospital  deficit;  it  is  met  out  of  the  funds  of  the  university.  The  income 
in  fees  amounts  to  $10,060. 

Laboratory  facilities :  Up  to  three  years  ago  the  department  was  a  didactic  school. 


VIRGINIA  315 

Since  then  it  has  been  revolutionized:  good  teaching  laboratories  in  all  necessary 
branches,  with  increased  provision  for  research,  have  been  equipped  and  put  in 
charge  of  enthusiastic  teachers  of  modern  training  and  ideals.  The  main  present 
lack  is  a  suitable  building  and  an  adequate  medical  library. 

Clinical  facilities:  The  University  Hospital  of  100  beds  (80  of  them  ward  beds)  is 
the  laboratory  of  the  clinical  teachers.1  Its  relation  to  the  medical  school  and  its 
organization  for  teaching  purposes  leave  nothing  to  be  desired.  Though  the  mate- 
rial has  not  yet  reached  proper  proportions,  it  is  increasing  and  is  skilfully  and 
effectively  used  to  train  the  student  body  in  the  technique  and  methods  of  scientific 
medicine.  The  surgical  side  is  in  this  respect  more  highly  organized  than  the 
medical. 

There  is  a  small  dispensary. 

Date  of  visit:  February,  1909. 

RICHMOND:  Population,  111,078. 

(2)  MEDICAL  COLLEGE  OF  VIRGINIA.  Organized  1838. 

Entrance  requirement:  Less  than  a  four-year  high  school  education.  The  registration 
office  is  most  systematically  conducted. 

Attendance:  206. 

Teaching  staff':  61,  of  whom  l(p  are  professors,  45  of  other  grade.  There  are  no  teach- 
ers giving  their  entire  time  to  medical  instruction. 

Resources  available  for  maintenance:  Fees,  amounting  to  $22,490,  and  an  annual  state 
appropriation  of  $5000. 

Laboratory  facilities :  The  school  occupies  an  imposing  building  with  ordinary  labora- 
tories for  pathology,  histology,  bacteriology,  physiology,  and  chemistry.  The  dis- 
secting-room is  in  poor  condition.  There  is  a  fair  museum  and  an  attractive  library 
with  some  recent  books,  in  charge  of  a  librarian. 

Clinical  facilities :  These  are  inadequate.  Close  by  is  the  Memorial  Hospital,  with 
about  40  beds  available  for  teaching.  Supplementary  facilities  are  enjoyed  in  the 
City  Hospital  and  elsewhere. 

The  dispensary  occupies  an  excellent  suite  of  rooms  and  has  a  fair  attendance. 

Date  of  visit:  February,  1909. 

(3)  UNIVERSITY  COLLEGE  OF  MEDICINE.  Organized  1893.  An  independent  institution. 
Entrance  requirement:  Less  than  a  four-year  high  school  education. 
Attendance:  121,  63  per  cent  from  Virginia. 

1 A  recent  gift  of  $50,000  is  now  available  for  the  extension  of  the  hospital. 


316  MEDICAL  EDUCATION 

Teaching  staff":  74,  of  whom  22  are  professors,  52  of  other  grade. 
Resources  available  for  maintenance:  Fees,  amounting  to  $14,975. 

Laboratory  facilities:  The  school  was  recently  destroyed  by  fire  and  now  occupies 
temporary  laboratory  quarters. 

Clinical  facilities:  These  are  inadequate.  The  school  adjoins  its  own  hospital,  with 
less  than  50  beds  available  for  teaching.  Supplementary  facilities  are  enjoyed 
elsewhere.  An  out-patient  obstetrical  service  is  well  organized. 
The  dispensary  has  a  fair  attendance. 

Datt  ofv'ult:  February,  1909. 

General  Considerations 

THE  destruction  by  fire  of  the  University  College  of  Medicine  at  Richmond  should 
precipitate  the  consolidation  of  the  two  independent  schools.  Separately  neither  of 
them  can  hope  greatly  to  improve  its  present  facilities,  which,  weak  in  respect  to 
laboratories  and  laboratory  teaching,  are  entirely  inadequate  on  the  clinical  side. 
Their  present  hospitals  utilized  together,  though  still  unsatisfactory,  would  at  any 
rate  be  much  more  nearly  adequate  than  is  either  hospital  taken  by  itself;  and  the 
combined  fees  would  furnish  much  better  laboratory  training  than  either  school  now 
gives.  A  single  independent  school  of  the  better  type  might  still  have  in  Virginia  a 
brief  term  of  prosperity, — the  more  so  as  the  medical  department  of  the  University 
of  Virginia  is  on  a  considerably  higher  basis. 

The  rapid  improvement  of  the  medical  department  of  the  University  of  Virginia 
in  the  last  three  years  is  one  of  the  striking  phenomena  of  recent  medical  school  his- 
tory. The  limitations  of  Charlottesville  have  been  acutely  felt;  the  university  is  pur- 
suing the  course  calculated  to  surmount  them.  It  faces  indeed  a  much  greater  out- 
lay than  it  has  yet  made,  for  larger  clinics  in  internal  medicine  and  obstetrics  must 
be  developed.  The  alternative  of  a  remote  department  diminishes  difficulty  of  one  kind 
only  to  create  difficulty  of  another.  A  remote  department  at  Norfolk  or  Richmond 
would  of  course  command  abundant  clinical  material;  but  could  it  preserve  univer- 
sity ideals?  The  present  resources  of  the  university  are  not  large  enough  to  stand  the 
strain  of  such  liberal  support  as  a  remote  department  needs  if  it  is  to  be  genuinely 
productive.  The  experience  of  a  few  years  warrants  the  belief  that  a  clinic  in  most 
lines,  for  a  school  of  200  students,  can  be  developed  at  Charlottesville  if  the  univer- 
sity can  afford  it.  Graduating  classes  of  50  easily  suffice  for  Virginia's  demand.  At 
any  rate,  so  much  is  evident:  in  Virginia,  as  elsewhere,  the  teaching  of  medicine  will 
fall  to  the  universities;  and  at  this  writing,  the  only  institution  available  is  the  Uni- 
versity of  Virginia. 


WISCONSIN  317 

WEST  VIRGINIA 

Population,  1,135,206.  Number  of  physicians,  1608.  Ratio,  1:706. 
Number  of  medical  schools,  1. 

MORGANTOWN,  Population,  2779. 

WEST  VIRGINIA  UNIVERSITY  COLLEGE  OF  MEDICINE.  Organized  1902.  A  half-school. 

An  organic  department  of  the  university. 
Entrance  requirement:  A  four-year  high  school  education,  though  applicants  not  thus 

qualified  are  admitted  as  special  students. 

Attendance:  18. 

Teaching  staff:  7  professors,  who  take  part  in  the  instruction  offered,  two  of  them 
giving  their  entire  time  to  this  department. 

Resources  available  for  maintenance:  The  department  is  carried  by  the  university.  Its 
income  in  fees  is  81000  (estimated). 

Laboratory  facilities:  The  school  is  fairly  equipped  to  do  elementary  work  in  anatomy, 
chemistry,  histology,  pathology,  and  bacteriology ;  less  well  in  physiology.  There 
is  no  library,  no  museum,  no  charts,  no  models,  or  other  teaching  accessories.  The 
work  and  interest  are  limited  to  routine. 

The  school  has  an  "affiliation"  with  the  College  of  Physicians  and  Surgeons  of 
Baltimore,  — an  independent  institution  over  which  West  Virginia  University  has 
neither  control  nor  influence.  [See  Maryland  (2).] 

Date  of  visit:  March,  1909. 

WISCONSIN 

Population,  2,356,874.  Number  of  physicians,  2518.  Ratio,  1 :  936. 
Number  of  medical  schools,  3. 

MADISON :  Population,  28,438. 

(1)  UNIVERSITY  OF  WISCONSIN  COLLEGE  OF  MEDICINE.  Organized  1907.  A  half-school. 
An  organic  part  of  the  university. 

Entrance  requirement:  Two  years  of  college  work,  including  sciences,  rigidly  enforced. 
Attendance:  49. 

Teaching  staff:  23  instructors,  who  take  part  in  the  work  of  the  department,  of  whom 
17  give  their  entire  time  to  it. 


318  MEDICAL  EDUCATION 

Resources  availablefor  maintenance:  The  department  is  maintained  out  of  the  general 
funds  of  the  university.  Its  budget  calls  for  $40,625. 

Laboratory  facilities:  Though  temporarily  housed,  the  laboratories,  complete  in  num- 
ber, are  admirably  equipped  with  respect  to  both  teaching  and  research.  A  suc- 
cessful effort  has  been  made  to  provide  facilities  worthy  of  students  on  a  two-year 
college  basis  and  of  teachers  deserving  opportunities  for  progressive  work.  The 
department  lacks  only  a  building  which  shall  bring  its  parts  together. 

Date  ofvifU:  May,  1909. 

MILWAUKEE:  Population,  337,117. 

(2)  MILWAUKEE  MEDICAL  COLLEGE.  A  stock  company,  organized  1894,  and  now  nomi- 
nally the  medical  department  of  Marquette  University. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 
Attendance:  168,  91  per  cent  from  Wisconsin. 
Teaching  staff":  67,  of  whom  30  are  professors,  37  of  other  rank. 
Resources  available  for  maintenance:  Fees  only,  amounting  to  $22,680. 

Laboratory  facilities:  Meager  facilities  are  provided  for  the  teaching  of  pathology 
and  bacteriology;  there  is  the  usual  chemical  laboratory;  anatomy  is  better  than 
ordinary.  Experimental  physiology  and  toxicology  are  taught  at  Marquette  Col- 
lege near  by;  the  equipment  is  slight. 

Clinical  facilities:  These  are  extremely  weak.  The  school  adjoins  Trinity  Hospital, 
which  is  practically  part  of  the  same  corporation.  It  has  75  beds,  largely  occupied 
by  pay  patients  and  given  up  almost  wholly  to  surgery;  teaching  is  limited  to 
amphitheater  clinics ;  weekly  clinics  are  also  held  at  the  County  Hospital,  five 
miles  distant. 

An  ill  equipped  dispensary  in  the  college  building  has  an  attendance  varying 
from  ten  to  twenty  a  day.  A  card  index  is  now  kept. 

Date  ofvitit:  February,  1910. 

(3)  WISCONSIN  COLLEGE  OF  PHYSICIANS  AND  SURGEONS.  Organized  1893.  An  indepen- 
dent institution,  nominally  the  medical  department  of  Carroll  College. 

Entrance  requirement:  A  four-year  high  school  education  or  its  equivalent. 
Attendance:  60,  85  per  cent  from  Wisconsin. 

Teaching  staff":  66,  of  whom  26  are  professors,  40  of  other  grade.  No  teacher  devotes 
his  entire  time  to  the  school. 

Resources  availablefor  maintenance:  Fees  only,  amounting  to  $8675  (estimated). 
Laboratory  facilities:  The  school  occupies  an  attractive  building  which  contains  an 


WISCONSIN  319 

ordinary  laboratory  for  elementary  chemistry,  another — poor  and  very  disorderly, 
without  animals — for  bacteriology;  the  room  given  to  histology  and  pathology 
is  clean,  contains  a  small  amount  of  well  kept  material,  and  is  adequate  to  routine 
elementary  work.  Anatomy  is  very  poor;  there  is  not  even  a  complete  skeleton. 
No  other  teaching  adjuncts  are  at  hand.  No  provision  is  made  for  even  demonstra- 
tive work  in  experimental  physiology. 

Clinical  facilities:  These  are  utterly  wretched.  The  school  gives  amphitheater  clinics 
only,  at  a  Catholic  hospital  across  the  street,  practically  all  of  whose  work  is  in 
surgery.  Acute  medical  cases  are  seen,  if  at  all,  twice  a  week  at  the  County  Hos- 
pital, five  miles  off.  A  neat  dispensary,  with  poor  records  and  with  no  laboratory 
or  other  equipment,  adjoins  the  school  building. 

Date  ofvitit:  February,  1910. 

General  Considerations 

WISCONSIN  presents  a  simple  problem  :  the  two  Milwaukee  schools  are  without  a  re- 
deeming feature.  It  is  claimed  that  the  examiner  representing  the  state  board  enforces 
a  four-year  high  school  standard;  but  it  has  been  impossible  to  procure  any  informa- 
tion at  all  from  this  official,  though  repeated  efforts  have  been  made  to  do  so.  Neither 
of  the  schools  meets  the  most  lenient  standards  in  respect  to  laboratory  outfit  or 
teaching;  and  as  for  clinical  facilities  they  are  hardly  more  than  nominal. 

A  western  state  so  admirably  organized  on  the  educational  side,  furnishing  ex- 
cellent college  opportunities  without  cost  to  the  student,  is  surely  in  position  to 
meet  Minnesota  and  Indiana  in  the  matter  of  practice  standards.  The  requirement  of 
a  year  or  two  of  college  work  as  preliminary  to  practice  would  quickly  leave  the  med- 
ical department  of  the  state  university  in  sole  control. 

This  department  has  wisely  resisted  efforts  to  make  of  it  a  divided  instead  of  a  half 
school;  nothing  worse  could  ever  happen  to  it  than  that  it  should  be  rounded  off  with 
a  clinical  end  at  Milwaukee, — made  up,  perhaps,  in  part  out  of  the  two  schools  now 
there.  When  the  time  comes  for  the  completion  of  the  department,  it  must  be  com- 
pleted at  Madison.  The  difficulties  due  to  the  size  and  residential  character  of  the 
town  are  not  insuperable.  There  is  not  the  least  doubt  that  wise  administration  can 
develop  on  the  site  of  the  university  a  medical  school  large  enough  to  train  the  doc- 
tors of  the  state.  But  its  scope  will  run  far  beyond  this  primary  duty ;  for  it  will  in- 
evitably be  a  producing  department.  Assuredly,  Wisconsin,  fortunate  beyond  almost 
all  other  states  in  the  concentration  of  its  higher  institutions  of  learning,  will  not  be 
guilty  of  the  folly  of  detaching  in  whole  or  part  the  medical  department  from  the 
university  whose  ideals  it  can  share  and  help  to  create. 


CANADA 

ALPHABETICALLY  ARRANGED  BY  PROVINCES 
Population,  6,945,228.  Number  of  physicians,  6736.  Ratio,  1 :  1030. 
Number  of  medical  schools,  8. 

MANITOBA 
WINNIPEG:  Population,  150,000. 

(1)  MANITOBA  MEDICAL  COLLEGE.  Organized  1883.  The  medical  department  of  the 
University  of  Manitoba,  the  connection  being  in  process  of  becoming  organic. 

Entrance  requirement:  The  University  Matriculation  Examination  or  its  actual 
equivalent.  The  medical  course  covers  five  years. 

Attendance:  115. 

Teaching  staff:  41,  of  whom  22  are  professors,  19  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $14,000. 

Laboratory  facilities:  Instruction  in  chemistry,  bacteriology,  histology,  and  pathology 
is  competently  given  by  the  University  of  Manitoba.  Other  branches  are  carried  on 
by  the  medical  faculty.  The  equipment  is  adequate  to  routine  instruction,  new, 
and  steadily  increasing.  There  is  a  beautifully  kept  collection  of  several  hundred 
wet  specimens.  Appearances  indicate  a  conscientious  and  intelligent  employment 
of  such  resources  as  the  school  has  had. 

Clinical  facilities:  The  excellent  Winnipeg  General  Hospital  of  400  beds  adjoins  the 
school.  The  school  faculty  is  practically  the  staff  of  the  free  wards.  The  relation 
between  school  and  hospital  is  admirable.  Students  work  freely  in  wards,  clinical 
laboratory,  operating-rooms,  obstetrical  ward,  etc. 
There  is  a  good  dispensary. 

DaU  of  visit:  May,  1909. 

NOVA  SCOTIA 
HALIFAX  (NovA  SCOTIA)  :  Population,  45,000  (estimated). 

(2)  HALIFAX  MEDICAL  COLLEGE.  Organized  in  1867.  An  independent  school  with  a  pe- 
culiar relationship  to  Dalhousie  University,  which  provides  satisfactorily  instruc- 
tion in  chemistry,  physics,  and  biology,  during  part  of  the  first  two  years  of  the 
five-year  course.  In  respect  to  all  else  the  medical  school  is  an  independent  in- 
stitution, though  its  students  are  practically  all  examined  for  their  degree  by  Dal- 
housie University.  The  university  thus  furnishes  part  of  the  first  two  years'  teaching 
and  is  the  final  examining  body ;  with  the  intervening  years  it  lias  nothing  to  do. 


CANADA  321 

Entrance  requirement :  .On  a  par  with  that  of  Dalhousie  University. 
Attendance :  63,  90  per  cent  from  Nova  Scotia. 

Teaching  staff:  33,  of  whom  16  are  professors.  There  are  no  full-time  instructors. 
(This  does  not  include  the  instructors  in  the  scientific  branches  furnished  by  Dal- 
housie University.) 

Resources  available  for  maintenance:  An  annual  appropriation  of  $1200  from  the 
provincial  government  and  fees  amounting  to  about  $5000.  Three-fourths  of  the 
fees  are  distributed  among  the  professors ;  one-fourth  provides,  with  the  govern- 
ment grant,  for  all  other  expense.  A  bequest  yielding  $200  per  annum  supports 
the  college  library. 

Laboratory  facilities :  This  disposition  of  funds  is  reflected  in  the  condition  of  the 
medical  college :  it  possesses  an  ordinary,  ill  smelling  dissecting-room  and  a  single 
utterly  wretched  laboratory  for  pathology,  bacteriology,  and  histology.  A  micro- 
scope is  provided  for  each  student.  Though  this  same  "  laboratory  "  serves  for  the 
provincial  board  of  health,  no  animals  are  used.  There  is  no  museum  worthy  the 
name,  and  no  laboratory  work  in  physiology  or  pharmacology.  The  laboratory  sci- 
ences have  been  starved  that  small  dividends  might  be  paid  to  generally  prosper- 
ous practitioners. 

Clinical  facilities:  Clinical  instruction  is  provided  at  the  Victoria  General  Hospital, — 
a  government  institution  of  some  200  beds,  open  to  the  medical  school.  About  70 
per  cent  of  the  cases  are  surgical.  The  staff  appointments  are  made  by  the  gov- 
ernment for  its  own  reasons ;  the  medical  college  is  forced  to  confer  professorships 
on  these  appointees.  Ward  classes  are  conducted ;  individual  cases  are  assigned, 
and  the  student's  notes  become  part  of  the  hospital  records.  Instruction  in  clinical 
microscopy  is  very  limited. 

Obstetrical  opportunities  barely  suffice.  Autopsies  are  performed  in  the  presence 
of  students,  who  report  on  them.  The  college  has  no  dispensary,  but  students  are 
required  to  attend  the  city  dispensary, — an  institution  within  which  the  medical 
school  has  no  authority.  The  attendance  is  fair. 

It  has  been  stated  above  that  except  during  part  of  the  first  two  years  Dalhousie 
University  has  no  teaching  responsibility  for  or  connection  with  Halifax  Medical 
College.  On  the  other  hand,  students  of  Halifax  Medical  College  are  examined  by 
the  medical  faculty  of  Dalhousie  University  and  obtain  the  Dalhousie  medical  de- 
gree. The  question  may  fairly  be  asked :  What  is  the  value  of  the  Dalhousie  degree 
in  medicine,  won  by  students  whose  opportunities  have  been  provided  by  Halifax 
Medical  College  ?  The  connection  is,  from  the  standpoint  of  Dalhousie  University, 
highly  objectionable. 

Date  of  visit :  October,  1909. 


322  MEDICAL  EDUCATION 

ONTARIO 
KINGSTON:  Population,  20,000. 

(3)  MEDICAL  DEPARTMENT  OF  QUEEN'S  UNIVERSITY.  Organized  1854.  The  relation  of 
the  medical  department  to  the  university  is  anomalous,  marking  a  period  of  transi- 
tion that  is  likely  soon  to  result  in  complete  integration. 

Entrance  requirement :  Heretofore  somewhat  below  that  of  the  arts  department  of 
the  university,  though  students  must  comply  with  the  requirements  of  the  pro- 
vince in  which  they  expect  to  practise.  The  medical  course  covers  five  years. 

Attendance :  208,  71  per  cent  from  Ontario. 
Teaching  staff ':  38,  16  being  professors. 

Resources  available  for  maintenance :  Income  in  fees,  $19,978.  A  fixed  percentage  of 
fees  is  annually  expended  on  buildings,  equipment,  and  maintenance.  The  re- 
mainder belongs  to  and  is  disbursed  by  the  medical  faculty. 

Laboratory  facilities :  The  laboratory  building  is  new  and  the  equipment  is  adequate 
to  intelligent  routine  work.  At  present,  physics,  chemistry,  and  physiology  are 
taught  in  the  university,  in  return  for  which  the  university  receives  a  part  of  the 
fees  of  the  students  instructed.  Full-time  professors  in  anatomy  and  pathology  are 
provided  by  the  medical  school.  A  museum  is  in  process  of  formation.  There  is  a 
small  collection  of  books  and  periodicals  in  the  faculty  room,  open  to  students. 

Clinical  facilities :  The  clinical  facilities  are  limited.  The  school  relies  mainly  on  the 
adjoining  Kingston  General  Hospital,  in  which  its  faculty  practically  constitutes 
the  staff.  The  average  number  of  beds  available  is  80,  but  they  are  well  used.  In 
addition  to  ward  work,  students  are  required  to  work  up  individual  cases  in  cor- 
rect form,  including  the  clinical  laboratory  aspects.  There  is  a  ward  for  infectious 
diseases.  Obstetrical  cases  are  too  few.  Post-mortems  are  secured  mainly  at  the 
Rockwood  Insane  Asylum.  Two  supplementary  hospitals  provide  additional  illus- 
trative clinical  material.  The  opportunities  for  out-patient  work  are  slight. 

Date  of  visit:  October,  1909. 

LONDON:  Population,  41,500. 

(4)  WESTERN  UNIVERSITY  MEDICAL  DEPARTMENT.  Established  1881.  Practically  an 
independent  school. 

Entrance  requirement:  Nominal.  The  student,  for  his  own  protection,  is  expected  to 
fulfil  the  requirements  of  the  place  in  which  he  intends  to  practise.  The  medical 
course  covers  four  years. 

Attendance:  104. 


CANADA  328 

Teaching  staff:  20,  of  whom  8  are  professors,  12  of  other  grade. 

Resources  available  for  maintenance:  Fees,  amounting  to  $11,590  (estimated). 

Laboratory  facilities:  These  consist  of  a  single  room  called  the  laboratory  of  patho- 
logy, bacteriology,  and  histology,  whose  equipment  consists  of  microscopes  and 
some  unlabeled  specimens, — no  microtome,  cut  sections,  incubator,  or  sterilizer 
being  visible, — a  wretched  chemical  laboratory,  and  an  ordinary  dissecting-room. 
There  is  no  outfit  for  physiology,  pharmacology,  or  clinical  microscopy,  and  no 
museum  deserving  the  name.  There  are  a  few  hundred  books,  locked  in  cases  to 
which  the  janitor  carries  the  key. 

Clinical  facilities:  These  are  entirely  inadequate.  They  are  confined  almost  wholly  to 
a  small  number  of  beds  in  the  municipal  hospital. 

The  school  has  no  dispensary. 
Date  of  visit:  October,  1909. 

TORONTO:  Population,  328,911. 

(5)  UNIVERSITY  OF  TORONTO  FACULTY  OF  MEDICINE.  Established  1887.  An  organic 
department  of  the  university. 

Entrance  requirement:  The  Junior  Matriculation  Examination,  strictly  enforced.  The 
course  covers  five  years. 

Attendance:  592. 

Teaching1  staff":  68,  of  whom  27  are  professors,  41  of  other  grade.  Ten  professors 
with  fifteen  assistants  give  their  entire  time  to  teaching  and  research. 

Resources  available  for  maintenance :  The  department  is  supported  out  of  the  general 
funds  of  the  university,  its  cost  being  considerably  in  excess  of  fees  received.  The 
latter  amount  to  $64,500. 

Laboratory  facilities :  The  laboratories  are  in  point  of  construction  and  equipment 
among  the  best  on  the  continent.  Increasing  attention  has  recently  been  devoted 
to  the  cultivation  of  research.  There  are  both  general  and  departmental  libraries, 
an  excellent  museum,  and  all  necessary  teaching  accessories. 

Clinical  facilities:  The  school  has  recently  perfected  a  very  intimate  relationship  with 
the  new  Toronto  General  Hospital,  by  which  its  faculty  obtains  complete  control 
of  the  clinical  advantages  of  some  500  beds.  Students  have  free  access  to  all  wards, 
clinical  laboratory,  dispensary,  etc.  Other  large  local  hospitals — general  and  special 
— are  also  available. 

Date  ofvurit:  March,  1909. 


824  MEDICAL  EDUCATION 

QUEBEC 
MONTREAL:  Population,  267,730. 

(6)  McGiLL  UNIVERSITY  MEDICAL  FACULTY.  Established  1824.  An  organic  depart- 
ment of  the  university. 

Entrance  requirement:  The  University  School  Leaving  Examination, strictly  enforced. 
The  medical  course  covers  five  years. 

Attendance:  328. 

Teaching  staff:  99,  of  whom  19  are  professors,  80  of  other  grade.  Ten  instructors  de- 
vote their  entire  time  to  teaching. 

Resources  available  for  maintenance:  The  department  has  separate  endowments  ag- 
gregating §350,000  and  is  assisted  out  of  the  general  university  funds.  Its  fees 
amount  to  §43,750;  its  budget,  $77,000. 

Laboratory  facilities:  The  laboratories  having  been  recently  injured  by  fire,  the  school 
is  now  waiting  the  completion  of  its  new  buildings,  for  which  ample  funds  have 
been  secured.  Meanwhile  its  temporary  quarters,  well  equipped  for  both  teaching 
and  research  in  all  departments,  show  what  energy  and  intelligence  can  accomplish 
in  the  face  of  disaster.  The  anatomical  and  pathological  museums  are  among  the 
most  famous  on  the  continent.  The  school  possesses  an  excellent  library  and  all 
necessary  teaching  accessories. 

Clinical  facilities :  These  are  excellent.  The  school  enjoys  a  most  favorable  relation 
to  two  large  hospitals,  of  about  500  beds,  besides  several  other  institutions.  Stu- 
dents work  freely  in  all  the  wards  and  clinical  laboratory. 
The  dispensary  service  is  large  and  admirable. 

Date  o/vifit:  March,  1909. 

(7)  LAVAL  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1878.  The  university  con- 
nection is  not  intimate. 

Entrance  requirement:  Indefinite,  depending  on  the  prospective  location  of  the  student. 
The  medical  course  covers  five  years. 

Attendance:  217. 
Teaching  staff':  8. 

Resources  available  for  maintenance:  Fees,  most  of  which  are  distributed  among  the 
teachers. 

Laboratory  facilities:  Chemistry  is  given  by  the  university.  Anatomy  is  limited  to 
dissecting.  A  single  laboratory  with  meager  equipment  is  assigned  to  pathology, 


CANADA  325 

bacteriology,  and  histology.  There  is  a  library  and  a  small  collection  of  speci- 
mens, not  all  labeled. 

Clinical  facilities:  The  school  has  access  to  two  hospitals,  containing  together  250 

beds.  The  dispensary  has  a  fair  attendance. 
Dale  of  visit:  March,  1909. 

QUEBEC:  Population,  70,000. 

(8)  LAVAL  UNIVERSITY  MEDICAL  DEPARTMENT.  Organized  1848.  An  organic  part  of 
Laval  University. 

Entrance  requirement:  Indefinite,  depending  on  the  student's  prospective  location. 
As  most  graduates  locate  in  the  province — French  being  the  language  of  in- 
struction— they  must  comply  with  the  provincial  requirement.  The  medical  course 
covers  five  years. 

Attendance:  92. 

Teaching-  staff":  22. 

Resources  available  for  maintenance:  Fees  and  an  appropriation  by  the  university. 

Laboratory  facilities:  Instruction  in  chemistry  and  physics  is  provided  by  the  univer- 
sity; in  the  medical  building,  recent,  though  not  extensive,  laboratory  provision 
is  made  for  anatomy,  histology,  bacteriology,  and  pathology.  There  is  no  experi- 
mental physiology  or  pharmacology.  A  library  for  students  and  a  museum  have 
been  started  lately.  The  buildings  are  admirably  kept. 

Clinical  facilities:  Clinical  instruction  in  medicine,  surgery,  and  pediatrics  is  given 
at  the  Charity  Hospital  (Hotel  Dieu),  to  the  free  wards  of  which  the  faculty  serves 
as  staff.  The  amount  of  material  is  limited  in  quantity;  the  staff  rotates  monthly. 
The  hospital  contains  a  clinical  laboratory,  in  which  instruction  is  given  in  con- 
nection with  ward  work.  The  fifth  year,  now  required,  and  a  proposed  reorganiza- 
tion of  staff  and  teaching  arrangements  promise  to  improve  the  instruction.  Ob- 
stetrical opportunity  is  abundant. 

The  dispensary  has  a  sufficient  attendance. 

Date  of  visit:  October,  1909. 

General  Considerations 

IN  the  matter  of  medical  schools,  Canada  reproduces  the  United  States  on  a  greatly 
reduced  scale.  Western  University  (London)  is  as  bad  as  anything  to  be  found  on  this 
side  the  line;  Laval  and  Halifax  Medical  College  are  feeble;  Winnipeg  and  Kingston 
represent  a  distinct  effort  toward  higher  ideals;  McGill  and  Toronto  are  excellent. 
The  eight  schools  of  the  Dominion  thus  belong  to  three  different  types,  the  best 
adding  a  fifth  year  to  their  advantages  of  superior  equipment  and  instruction. 


326  MEDICAL  EDUCATION 

At  this  moment  the  needs  of  the  Dominion  could  be  met  by  the  four  better  Eng- 
lish schools  and  the  Laval  department  at  Quebec.  Toronto  has  practically  reached 
the  limits  of  efficiency  in  point  of  size;  McGill  and  Manitoba  are  capable  of  consid- 
erable expansion.  The  future  of  Kingston  is  at  least  doubtful.  It  could  certainly 
maintain  a  two-year  school ;  for  the  Kingston  General  Hospital  would  afford  patho- 
logical and  clinical  material  amply  sufficient  up  to  that  point.  But  the  clinical  years 
require  much  more  than  the  town  now  supplies.  Its  location — halfway  between 
Montreal  and  Toronto,  on  an  inconvenient  branch-line — greatly  aggravates  the  diffi- 
culties due  to  the  smallness  of  the  community.  The  rapid  development  of  the  North- 
west Territory  will  undoubtedly  hasten  the  growth  of  the  Winnipeg  school;  other 
institutions  will  in  time  be  established  nearer  the  Pacific  coast  as  the  country  grows 
in  population. 

The  legal  standard  in  the  Dominion  has  not  thus  far  been  high ;  but  it  has  prac- 
tically been  elevated  a  year  by  the  general  movement  to  prolong  the  course  to  five 
years.  Meanwhile,  the  high  quality  of  instruction  offered  by  McGill  and  Toronto  to 
students  who  enter  on  less  than  a  four-year  high  school  education  proves  that  our 
trouble  in  the  United  States  has  been  at  bottom  not  less  one  of  low  ideals  than  of 
low  standards.  Indeed,  where  ideals  are  low,  there  are  no  standards;  and  where  ideals 
are  high,  the  standard,  even  though  low,  is  at  any  rate  so  definite  that  it  furnishes  a 
sure  starting-point  towards  a  clearly  apprehended  goal.  The  low  standard  school  in 
the  United  States  has  had  no  such  starting-point  and  no  such  goal. 


APPENDIX 

TABLE  SHOWING  NUMBER  IN  FACULTY,  ENROLMENT, 
FEE  INCOME,  BUDGET  OF  SCHOOLS  BY  STATES 


INSTITUTION 
(Half-schools  marked  *) 

Num- 
ber of 
Pro- 
fes- 
sors 

Number 
of 
Other  In- 
structors 

Number 
Students 

Total 
Annual 
Income 
from  Fees 

Annual 
Budget* 

ALABAMA 
1.  Birmingham  Medical  College  

18 

12 

185 

$  14  550  * 

2.  University  of  Alabama,  Medical  Department  

g 

17 

204 

17  300* 

ARKANSAS 
8.  University  of  Arkansas,  Medical  Department  

18 

17 

179 

14.100  l 

4.  College  of  Physicians  and  Surgeons  (Little  Rock)  

25 

0 

81 

6  450* 

CALIFORNIA 
5.  College  of  Physicians  and  Surgeons  (Los  Angeles)  

28 

18 

32 

40751 

6.  California  Eclectic  Medical  College  

26 

1 

9 

1  0601 

7.  Los  Angeles  College  of  Osteopathy  

19 

"Afore  than 

37  600  l 

8.  Pacific  College  of  Osteopathy  

19 

19 

250" 
85 

12  760  l 

0.  Oakland  College  of  Medicine  and  Surgery  

13 

19 

17 

2  760  l 

10.  Hahnemann  Medical  College  of  the  Pacific  

13 

22 

23 

2,685  * 

11.  College  of  Physicians  and  Surgeons  (San  Francisco)  

23 

30 

70 

7.716  ' 

12.  Leland  Stanford  Junior  University,  College  of  Medicine  

16 

5 

16* 

13.  University  of  California,  Medical  Department  

12 

48 

36 

7,004 

$33,396 

COLORADO 
14.  University  of  Colorado,  School  of  Medicine  

25 

20 

86 

4.043 

28.000 

15.  Denver  and  Gross  College  of  Medicine  (University  of  Denver)  

44 

35 

109 

12.624  l 

CONNECTICUT 
16.  Yale  Medical  School  

14 

50 

138 

16,325 

43,311 

DISTRICT  OF  COLUMBIA 
17.  George  Washington  University,  Department  of  Medicine  

26 

44 

117 

21,833 

23,779 

18.  Georgetown  University,  Department  of  Medicine  

20 

54 

89 

11.000 

19.  Howard  University,  Medical  Department      

22 

30 

205 

26,000 

40,000* 

GEORGIA 
20.  Atlanta  College  of  Physicians  and  Surgeons    

20 

31 

286 

28,000 

21.  Atlanta  School  of  Medicine                                            

17 

27 

230 

20,000  ' 

22.  Georgia  College  of  Eclectic  Medicine  and  Surgery    

14 

6 

66 

6.666  * 

23.  Hospital  Medical  College                                                 

16 

43 

3,960  l 

24.  Medical  College  of  Georgia  (University  of  Georgia)    

18 

15 

99 

6.835 

ILLINOIS 
25.  Rush  Medical  College  (University  of  Chicago)  

89 

141 

488 

60.485* 

82.462 

Forwarded  

562 

665 

3.142 

$343,699 

1  Estimated.  *  First  year  in  operation. 

3  Absence  of  information  under  this  heading  may  mean  one  of  several  things :  in  proprietary  schools  there  is  no  budget,  because  no  plant 
are  made, — necessary  expenses  are  met  and  the  balance  is  divided  or  is  used  to  reduce  debts ;  in  many  university  departments  the  expense 
incurred,  while  much  greater  than  fee  income,  is  so  involved  with  expense  incurred  for  other  laboratory  purposes  that  it  cannot  be  sepa- 
rated. In  such  instances,  it  cannot  be  definitely  stated  what  the  cost  of  the  department  is. 
*  Includes  state  appropriation  of  $5000  which  pays  for  scholarships. 
8  First  two  years.  University  of  Chicago :  $33.000.  Third  and  fourth  years.  Rush  Medical  College :  t87J£5. 


INSTITUTION 
(Half-*choola  marked  •) 

dum- 
ber of 
Pro- 
fe*- 
•ort 

Kumber 
of 
Other  In- 
structors 

Number 
Students 

Total 
Annual 
Income 
from  Fees 

Annual 
Budget 

562 

665 

3  142 

$343  699 

ILLINOIS  (COXTWCTO) 
28.  Northwestern  University  Medical  School  

64 

89 

522 

89076 

$88,861 

J7  College  of  Physicians  and  Surgeons  (University  of  Illinois)  

42 

156 

517 

80  155  ' 

American  Medical  Missionary  College  

See 

J8.  Hahnemann  Medical  College  and  Hospital  of  Chicago  

38 

Michigan 
46 

130 

14,300  l 

29.  Chicago  College  of  Medicine  and  Surgery  

87 

84 

366 

43,430' 

SO.  Bering  Medical  College  

30 

14 

32 

3,360  * 

31.  Illinois  Medical  College  ;  

38 

35 

69 

9,175  l 

Si.  Bennett  Medical  College  

21 

21 

181 

19,380  ' 

S3  College  of  Medicine  and  Surgery  —  Physio-medical  

33 

9 

33 

2,935  ' 

34.  Jenner  Medical  College  

28 

9 

112 

12,880' 

$3  National  Medical  University    

36 

150 

22  500' 

M.  Reliance  Medics!  College  

23 

21 

83 

9,945' 

37.  Littlejohn  College  of  Osteopathy  

43 

75 

11,250  ' 

INDIANA 
38.  Indiana  University,  School  of  Medicine  

99 

76 

266 

31,240  ' 

30.  'Valparaiso  University,  Medical  Department  

25 

IOWA 
40.  Drake  University  College  of  Medicine  

16 

29 

1O6 

9505 

12  417 

41.  Still  College  of  Osteopathy  

13 

2 

115 

17.250' 

42.  State  University  of  Iowa,  College  of  Medicine  

12 

20 

267 

13,707 

35,216  * 

43.  State  University  of  Iowa,  College  of  Homeopathic  Medicine  

10 

15 

42 

1,864 

6,453* 

KANSAS 
44.  University  of  Kansas,  School  of  Medicine  

24 

39 

89 

5,030 

40,000 

45.  Western  Eclectic  College  of  Medicine  and  Surgery  

30 

2 

21 

1,600' 

40.  Kansas  Medical  College  (Washburn  College)  

81 

16 

65 

4876 

KENTUCKY 
47.  University  of  Louisville,  Medical  Department  

40 

50 

6OO 

75,126 

48.  Southwestern  Homeopathic  Medical  College  :.  

12 

15 

13 

1,100' 

40.  Louiiville  National  Medical  College  

17 

6 

40 

2,660  ' 

Forwarded  

1.289 

1.269 

7,061 

$825  942 

Estimated. 


*  The  university  hospital  budget  it  $SS,lk5. 


•Hospitnl  budget,  $781.7. 


INSTITUTION 
(Half-schools  marked  *) 

Num- 
ber of 
Pro- 
/«- 
sort 

Number 
of 
Other  In- 
structor* 

Number 
of 
Students 

Total 
Annual 
Income 
from  Feet 

Annual 
Budget 

Carried  forward  

1  289 

1  269 

7  061 

$826  942 

LOUISIANA 
50.  Tulane  University  of  Louisiana,  Medical  Department  

17 

58 

439 

67,600 

$101.781 

51.  Flint  Medical  College  

3 

9 

24 

1  3OO 

MAINE 
52.  Medical  School  of  Maine  (Bowdoin  College)  

14 

21 

81 

8.100 

16,700 

MARYLAND 
53.  Johns  Hopkins  University,  Medical  Department  

23 

89 

297 

60542 

102  429 

54.  College  of  Physicians  and  Surgeons  (Baltimore)  

21 

38 

252 

39  000  l 

55.  University  of  Maryland,  School  of  Medicine  

24 

37 

316 

44  630 

56.  Baltimore  Medical  College  

20 

43 

892 

33.424 

57.  Woman's  Medical  College  of  Baltimore  

18 

13 

22 

2  000' 

58.  Maryland  Medical  College  

21 

18 

95 

7,460  l 

58.  Atlantic  Medical  College  

12 

35 

43 

3  905  * 

MASSACHUSETTS 
60.  Harvard  University  Medical  School  

23 

16O 

285 

72,037 

261.389 

61.  Boston  University  School  of  Medicine  

29 

85 

90 

12,762  ' 

62.  Tufts  College  Medical  School  

33 

70 

384 

59.O93 

63.  College  of  Physicians  and  Surgeons  (Boston)  

30 

15 

172 

10,000  l 

64.  Massachusetts  College  of  Osteopathy  

19 

16 

90 

11.4O01 

MICHIGAN 
65.  University  of  Michigan,  Department  of  Medicine  and  Surgery  

22 

41 

389 

34,093 

83.00O1 

66.  University  of  Michigan  Homeopathic  College  

15 

12 

80 

4.515 

16.400* 

67.  American  Medical  Missionary  College    

22 

10 

75 

4,778  ' 

68.  Detroit  College  of  Medicine                              

25 

79 

161 

22,000  l 

69.  Detroit  Homeopathic  College  

17 

18 

34 

3.010  l 

MINNESOTA 
70.  University  of  Minnesota  College  of  Medicine  and  Surgery  

49 

71 

174 

16,546 

71.886 

MISSISSIPPI 

12 

7 

100 

7,600' 

14 

13 

39 

3,600 

16.000 

MISSOURI 
73  *  University  of  Missouri  School  of  Medicine  

8 

6 

47 

2.820 

31,000 

1,783 

2,171 

11,142 

11  367  757 

'  Estimated. 


lNot  including  university  hospital  budget  of  $70,000. 


'Hospital  budget,  $31,000. 


INSTITUTION 
(Half-schools  marked  *) 

K  'um- 
ber of 
Pro- 
fes- 
sors 

dumber 
of 
Other  In- 
structors 

dumber 
Students 

Total 
Annual 
Income 
from  Feet 

Annual 
Budget 

1  783 

2,171 

11  142 

fl  367  767 

MISSOURI  (CoxnircKD) 
74.  University  Medical  College    

30 

35 

174 

17  60O1 

75  Kansas  City  Habnemann  Medical  College  ..       

33 

g 

59 

5  900* 

75.  Central  College  of  Osteopathy  

20 

40 

4,600  * 

77  American  School  of  Osteopathy  

12 

11 

560 

89,600  l 

78.  Ensworth  Medical  College  

32 

8 

72 

7,060  l 

79  Washington  University,  Medical  Department  ..  

48 

51 

178 

21,000 

361,265* 

80  St.  Louis  University  School  of  Medicine  

39 

82 

243 

26,630  l 

37,000* 

81  St.  Louis  College  of  Physicians  and  Surgeons  

25 

24 

224 

16,035  l 

61.  Barnes  Medical  College  

39 

25 

124 

12,400  l 

83.  American  Medical  College  

25 

3 

28 

8,801  * 

84.  Hippocratean  School  of  Medicine  

30 

8 

81 

3,315  * 

NEBRASKA 
M.  Univfmity  of  Nchraikn,  College  of  Medicine  

38 

46 

122 

4,905 

20,612 

88  Lincoln  Medical  College  (Cotner  University)  

34 

42 

3  794  l 

87.  John  A.  Creighton  Medical  College  (Creighton  University)  

28 

21 

175 

17,850  * 

NEW  HAMPSHIRE 
88.  Dartmouth  Medical  School  (Dartmouth  College)  

17 

7 

68 

6,583  * 

NEW  YORK 
80.  Albany  Medical  College  (Union  University)  

16 

78 

180 

20,276 

80.  University  of  Buffalo  Medical  Department  

38 

59 

193 

31,984 

81.  College  of  Physicians  and  Surgeons,  New  York  City  (Columbia  University) 
98.  Cornell  University  Medical  College  

38 
32 

138 
100 

812 

207 

75.600 
24,410 

239.072  3 
)  209.888  (^£ 

9S.  Eclectic  Medical  College  of  the  City  of  New  York  

16 

29 

96 

8,311 

'  32,840  (Ithac 

94.  Ford  ham  University  School  of  Medicine  

82 

40 

42 

7,330  ' 

95.  Long  Island  College  Hospital  

9 

85 

360 

61,398 

9ft.  New  York  Homeopathic  Medical  College  

31 

84 

159 

18,658 

97.  New  York  Medical  College  for  Women  

23 

22 

24 

2.545 

98.  University  and  Bellevue  Hospital  Medical  College  (New  York  University) 
99.  Syracuse  University,  College  of  Medicine  

87 
16 

127 
42 

408 
161 

76,115 
28,861 

87.116 

Forwarded 

2.52O 

3.254 

15.4O4 

$1,963.118 

1  E»t  imated. 


1  Hospital  budget,  $90.000. 


'Including  Sloane  Maternity  Hospital  and  Vanderbilt  Clinic. 


INSTITUTION 
(.Half-schools  marked  *) 

Num- 
ber of 
Pro- 
fes- 
sors 

Number 
of 
Other  In- 
structors 

Number 
of 
Students 

Total 
Annual 
Income 
from  Fees 

Annual 
Budget 

2  520 

3  264 

15  404 

$1  953  118 

ORTH  CAROLINA 
K).  *  University  of  North  Carolina,  Medical  Department  

10 

5 

74 

6.6OO 

1  12  000 

1.  North  Carolina  Medical  College  

19 

13 

94 

8  345  ' 

2.  Leonard  Medical  School  (Shaw  University)  

8 

1 

125 

2  846 

>S.  *Wake  Forest  College,  School  of  Medicine  

6 

53 

2,225 

ORTH  DAKOTA 
14.  *State  University  of  North  Dakota,  College  of  Medicine  

9 

7 

9 

450 

6  300 

HIO 
5.  Ohio-Miami  Medical  School  (University  of  Cincinnati)  

50 

76 

197 

26,345 

*6.  Eclectic  Medical  Institute  

12 

12 

86 

7,500* 

•7.  Pulte  Medical  College  

24 

12 

16 

1,325  a 

»8.  Cleveland  College  of  Physicians  and  Surgeons  

18 

41 

89 

9.5201 

9.  Cleveland  Homeopathic  Medical  College  

30 

31 

46 

5,750  ' 

0.  Western  Reserve  University,  Medical  Department  

18 

82 

98 

11,000 

63,000 

1.  Starling-Ohio  Medical  College  

32 

28 

220 

27,500  l 

2  Toledo  Medical  College  

16 

32 

32 

3,240  J 

KLAHOMA 
3.  *State  University  of  Oklahoma,  School  of  Medicine  

9 

22 

600 

4.  Epworth  University  College  of  Medicine  

28 

14 

51 

42851 

REGON 
5.  University  of  Oregon,  Medical  Department  

14 

27 

72 

8,000  * 

15 

1 

29 

3,580  l 

ENNSYLVANIA 

26 

131 

546 

104,612 

131.255* 

8.  Jefferson  Medical  College  

22 

100 

591 

102,995 

9.  Medico-Chirurgical  College  of  Philadelphia   

23 

86 

480 

48.281  * 

!0.  Woman's  Medical  College  of  Philadelphia      

25 

27 

125 

15,480 

1  Hahnemann  Medical  College,  Philadelphia  

27 

45 

182 

18.500 

•2  Temple  University,  Department  of  Medicine  

15 

70 

136 

17,000  * 

•3  Philadelphia  College  of  Osteopathy          

11 

7 

126 

18.900  > 

!4.  University  of  Pittsburgh  Medical  Department  

43 

60 

315 

48,500 

Forwarded  

3,030 

44.62 

19.218 

$2,456.397 

Estimated. 


1  Exclusive  of  hospital  and  dispensary. 


INSTITUTION 
(Half-schools  marked  *) 

Num- 
ber of 
Pro- 

/«*- 
tors 

Number 
of 
Other  In- 
structors 

Number 
of 
Students 

Total 
Annual 
Income 
from  Fees 

Annual 
Budget 

3,030 

4,162 

19,218 

$2,456,397 

SOUTH  CAROLINA 
125  Medical  College  of  the  State  of  South  Carolina    

11 

23 

213 

19447 

SOUTH  DAKOTA 
1M  'University  of  South  Dakota,  College  of  Medicine  

5 

5 

7 

660 

TENNESSEE 
127  Chattanooga  Medical  College  (University  of  Chattanooga)  

11 

14 

112 

4,290  ' 

Ijg,  Tennessee  Medical  College  (Lincoln  Memorial  University)  

26 

5 

82 

4,994 

129  Knoxville  Medical  College  

9 

2 

23 

1.0201 

130  College  of  Physicians  and  Surgeons  (Memphis)  

22 

26 

77 

7.400  ' 

12 

23 

442 

34,600  ' 

192  University  of  West  Tennessee  Medical  Department    

14 

40 

2,000  * 

ISA.  Universities  of  Nashville  and  Tennessee,  Medical  Department  

26 

29 

207 

26,000  ' 

134.  Vanderbilt  University,  Medical  Department  

17 

23 

200 

26,250 

135  Meharry  Medical  College  (Walden  University)  

12 

14 

275 

20.310 

$23,946 

TEXAS 
ISfl  Baylor  University  College  of  Medicine  

16 

13 

53 

7,735  * 

17 

15 

68 

7,150  * 

138.  Fort  Worth  University,  Medical  Department  

14 

33 

100 

10,600  ' 

ISO.  University  of  Texas,  Medical  Department  

e 

17 

206 

6,500 

63.342  ' 

UTAH 
140.  *  University  of  Utah,  Department  of  Medicine  

6 

10 

18 

1,405 

10,000 

VERMONT 
141  University  of  Vermont  College  of  Medicine          ..             

18 

16 

156 

21,388 

VIRGINIA 
142.  University  of  Virginia,  Department  of  Medicine  

12 

19 

89 

10,060 

52,196s 

14S.  Medical  College  of  Virginia  

16 

46 

2O6 

22,490  * 

144.  University  College  of  Medicine  

22 

62 

121 

14.976 

WEST  VIRGINIA 
149.  *  West  Virginia  University,  College  of  Medicine       .           

7 

18 

1,000* 

WISCONSIN 
140.  •  University  of  Wisconsin,  College  of  Medicine   

7 

16 

49 

40,625 

147.  Milwaukee  Medical  College  (Marquette  University)  

30 

37 

168 

22,680  * 

3,369 

4.697 

22,148 

$2.729,251 

1  Estimated. 


1  Hotpital  budget.  $39,611. 


1 Including  hospital  deficit. 


INSTITUTION 

(Half-schools  marked  *) 

Num- 
ber of 
Pro- 
fes- 
sors 

Number 
of 
Other  In- 
structors 

Number 
Students 

Total 
Annual 
Income 
from  Fees 

Annual 
Budget 

Carried  forward  .  .         

3,369 

4  597 

22,148 

$2,729,251 

WISCONSIN  (CONTINUED) 
148.  Wisconsin  College  of  Physicians  and  Surgeons  

26 

40 

60 

8,675 

MANITOBA 
149.  Manitoba  Medical  College  (University  of  Manitoba)1  

22 

19 

115 

14,000 

NOVA  SCOTIA 
150.  Halifax  Medical  College  (Dalhousie  University)  

16 

17 

63 

5,000 

$6,200 

ONTARIO 
151   University  of  Toronto,  Faculty  of  Medicine1  

27 

41 

592 

64,500 

152  Queen's  University,  Medical  Faculty1  

16 

22 

208 

19,978 

153  Western  University.  Medical  Department*  

8 

12 

104 

11  590 

QUEBEC 
154  McGill  University,  Medical  Faculty1  

19 

80 

328 

43,750 

77.000 

f  Montreal  

8 

217  ~\ 

L55:  Laval  University,  Medical  Department1  -I 

22 

92  / 

Total  

3,533 

4,828 

23,927 

$2.896,744 

, 

Five-year  course. 


1  Four-year  course. 


INDEX 


INDEX 


ACCREDITED  high  schools,  31. 

Admission  requirements  in  medical  schools,  10, 

11,  22-38,  47-50,  168. 
Alabama :  / 

University  of  Alabama,  85,  90,  123,  126, 

139,  185. 

Birmingham  Medical  College,  36,  122,  185. 
Alabama,  University  of  (see  under  Alabama). 
Albany    Medical    College,   Union  University 

(see  under  New  York). 
American   College    of  Osteopathy  (see  under 

Missouri). 

American  Medical  Association,  10. 
American  Medical  College  (see  under  Missouri). 
American  Medical  Missionary  College  (see  un- 
der Michigan). 
Anatomy,  61,  83. 

Apportionment  of  studies  in  medical  schools,  76. 
Apprenticeship  system,  3,  9. 
Approved  high  schools,  31. 
Arkansas : 

University  of  Arkansas,   10,  12,  86,  120, 

141,  151,  187. 
College  of  Physicians  and  Surgeons,  Little 

Rock,  7,  12,  114,  187. 

Arkansas,  University  of  (see  under  Arkansas). 
Army  Medical  School,  Washington,  D.C.  (see 

under  District  of  Columbia). 
Atlanta  College  of  Physicians  and  Surgeons 

(see  under  Georgia). 

Atlanta  School  of  Medicine  (see  under  Georgia). 
Atlantic  Medical  College  (see  under  Maryland). 
Autopsies  at  medical  schools,  84,  88. 

BACTERIOLOGY,  67,  85. 

Baltimore  Medical  College  (tee  under  Mary- 
land). 

Bardeen,  C.  R.,  58  (note). 

Barker,  L.  F.,  58  (note). 

Barnes  Medical  College  (see  under  Missouri). 

Baylor  University  (see  under  Texas). 

Bellevue  Hospital,  New  York  City,  84,  110, 
131,  275. 

Bennett  Medical  College  (see  under  Illinois). 

Bigelow,  Henry  J.,  9. 

Billings,  John  S.,  46.  [26. 

Biology,  teaching  of,  in  medical  education,  25, 

Birmingham  Medical  College  (see  under  Ala- 
bama). 


Boards  of  medical  examiners,  state,  167-173. 
Bond,  Thomas,  4,  7. 

Boston  University  (see  under  Massachusetts). 
Bowdoin  College,   Medical  School   of  Maine 

(see  under  Maine). 
Brooklyn    Postgraduate    Medical   School  (see 

under  New  York). 
Budget  of  a  medical  school,  129-133. 
Buffalo,  University  of  (see  under  New  York). 

CABOT,  R.  C.,  8,  99. 
California : 

University  of  California,  Los  Angeles,  115, 

121,  141,  189. 
University  of  California,  San  Francisco,  28, 

29,  72,  73,  119,  150,  192,  195. 
California  Medical  College,  120,  140,  190. 
Hahnemann  Medical  College  of  the  Pacific, 

10,  159-161. 

Leland  Stanford  Junior  University  (Cooper 

Foundation),  28,  29,  72,  84,  114,  193,  196. 

Los  Angeles  College  of  Osteopathy,  164, 190. 

College  of  Medicine  and  Surgery,  Oakland, 

82,  85,  115,  191. 

Pacific  College  of  Osteopathy,  164,  166, 191. 
University  of  Southern  California,  141. 
College  of  Physicians  and  Surgeons,  Los 

Angeles,  12,  82,  188. 
College  of  Physicians  and  Surgeons,  San 

Francisco,  39,  81,  86,  194. 
California,  University  of  (see  under  California). 
California  Medical  College  (see  under  California). 
Canada,  proper  distribution  of  medical  schools 
in,  150.  [souri). 

Central  College  of  Osteopathy  (see  under  Mis- 
Chattanooga,  University  of  (see  under  Tennes- 
see). 
Chemistry,  teaching  of,  in  medical  education, 

25,  26,  83,  87. 

Chicago,  University  of  (see  under  Illinois). 
Chicago  College  of  Medicine  and  Surgery,  Val- 
paraiso University  (see  under  Illinois). 
Chicago  Ear,  Eye,  Nose,  and  Throat  College 

(see  under  Illinois). 

Chicago  Polyclinic  (tee  under  Illinois). 
Cincinnati,  University  of,  Ohio-Miami  Medical 

College  (see  under  Ohio). 

Cleveland  Homeopathic  Medical  College  (te* 
under  Ohio). 


340 


INDEX 


Clinical  teaching,  91-93,  102,  105,  111,  119. 
College  work  as  preliminary  to  medical  educa- 
tion, 23-28. 
Colorado : 

University  of  Colorado,  21,  39,  72,  107,  119, 

150,  197. 

University  of  Denver,  Denver  and  Gross 
College  of  Medicine,  12,  39,  78,  81,  82,  88, 
113,  115,  118,  121,  141,  197,  199. 
Colorado,  University  of  (tee  under  Colorado). 
Columbia  University,  College  of  Physicians  and 

Surgeons  (tee  under  New  York). 
Cook  County  Hospital,  110,  218,  219. 
Conditions  on  admission  to  medical  schools,  29. 
Connecticut : 

Yale  University,  5,  8,  10,  28,  29,  38,  39,  72, 

111,  117,  118,  121,  134,  147,  199,  263. 
Cornell  University  (tee  under  New  York). 
Cost  of  a  medical  education,  43. 
Cost  of  a  medical  school,  128. 
Creighton,  John  A.,  Medical  College  (tee  under 
Nebraska). 

I  )  \  i  HOI-SIE  University,  Halifax  Medical  College 

(tee  under  Nova  Scotia). 

Dartmouth  College  (tee  under  New  Hampshire). 
Davis,  Nathan  Smith,  10. 
Delafield,  Francis,  11. 

Denver,  University  of,  Denver  and  Gross  Col- 
lege of  Medicine  (tee  under  Colorado). 
Detroit  College  of  Medicine  (tee  under  Michi- 
gan). 

Detroit  Homeopathic  College  (tee  under  Michi- 
gan). 

Didactic  system  of  teaching  medicine,  9,  22. 
Dispensary,  95,  96,  120-123,  160,  163. 
Dissecting,  84,  87,  88. 
Distribution  of  physicians,  15-18,  143-156. 
District  of  Columbia : 

Army  Medical  School,  202. 

George  Washington  University,  22,  31,  32, 

39,  112,  201. 
Georgetown  University,  13,  39,  81,  82,  84, 

85,  139,  201. 
Howard  University,  147, 151,  181, 202, 203, 

282 

Navy  Medical  School,  203. 
Divided  medical  schools,  72-75. 
Drake,  Daniel,  7. 

Drake  University  (tee  under  Iowa). 
Dudley,  Benjamin,  15. 


ECLECTIC    Medical   College   (tee   under   New 

York). 

Eclectic  Medical  Institute  (tee  under  Ohio). 
Eclectic  medical  sect,  158,  162,  163,  172. 
Eliot,  President,  12. 

Ensworth  Medical  College  (tee  under  Missouri). 
Epworth  University  (tee  under  Oklahoma). 
Examinations  for  admission  to  medical  schools, 

31. 

FEES  at  medical  schools,  44,  77,  81,  133,  137, 

166. 
Financial  administration  of  medical  schools, 

125-142. 

Flint  Medical  College  (tee  under  Louisiana). 
Fordham  University  (tee  under  New  York). 
Fort  Worth  University  (tee  under  Texas). 

GEORGETOWN  University  (tee  under  District  of 

Columbia). 

George  Washington  University  (tee  under  Dis- 
trict of  Columbia). 
Georgia : 

Atlanta  College  of  Physicians  and  Sur- 
geons, 22,  37,  39,  85,  88,  203. 
Atlanta  School  of  Medicine,  36,  85, 88,  204. 
University  of  Georgia,  10,  13,  36,  88,  139, 

141,  205,  207. 
Georgia  College  of  Eclectic  Medicine  and 

Surgery,  120,  123,  204. 
Hospital  Medical  College,  Atlanta,  123, 162, 

205. 

Georgia,  Medical  College  of  (see  under  Georgia). 
Georgia,  University  of  (tee  under  Georgia). 
Georgia  College  of  Eclectic  Medicine  and  Sur- 
gery (tee  under  Georgia). 
German  medical  schools,  cost  of,  130. 
Grady  Hospital,  Atlanta,  Georgia,  36. 

HAHNEMANN  Medical  College,  Chicago,  Illi- 
nois (tee  under  Illinois). 

Hahnemann  Medical  College  and  Hospital, 
Philadelphia,  Pennsylvania  (tee  under  Penn- 
sylvania). 

Hahnemann  Medical  College  of  the  Pacific  (tee 
under  California). 

Halifax  Medical  College,  Dalhousie  University 
(tee  under  Nova  Scotia). 

Harvard  University  (tee  under  Massachusetts). 

Hektoen,  Professor,  66. 

Hering  Medical  College  (tee  under  Illinois). 

High  school  development  in  the  south,  40. 


INDEX 


Hippocratean  College  of  Medicine  (tee  under 
Missouri). 

History  of  medical  education,  52,  53. 

Homeopathic  medical  sect,  158-162,  172. 

Hospital  Medical  College,  Atlanta,  Georgia  (see 
under  Georgia). 

Hospital  Medical  School,  95-103,  106-120,  160. 

Howard  University  (see  under  District  of  Co- 
lumbia). 

Hubbard,  Dr.  George  W.,  181. 

ILLINOIS: 

Bennett  Medical  College,  33,  87,  88,  117, 

210,  216. 

University  of  Chicago,  Rush  Medical  Col- 
lege, 28,  43,  72,  76,  107,  109,  114,  119, 
136,  178,  207,  217-219. 

Chicago  Ear,  Eye,  Nose,  and  Throat  Col- 
lege, 215. 

Chicago  Polyclinic,  176,  215. 

Hahnemann  Medical  College,  82,  84,  118, 
120,  159,  160,  161,  214,  216. 

Hering  Medical  College,  112,  160, 161,  213, 
216. 

University  of  Illinois,  College  of  Physicians 
and  Surgeons,  12,  19,  38,  39, 80-82, 84,  85, 
109,  114,  140,  208,  217-219. 

Illinois  Medical  College,  7,  33,  87,  211,  216. 

Reliance  Medical  College,  33,  211,  216. 

Illinois  Postgraduate  School,  216. 

Jenner  Medical  College,  33,  87,  122,  176, 

211,  216. 

Littlejohn  College  of  Osteopathy,  87,  165, 

214,  216. 

College  of  Medicine  and  Surgery :  Physio- 
Medical,  36,  117,  122,  213,  216. 
National  Medical  University,  33,  86,  87, 

120,  212,  216. 
Northwestern  University,  12,  28,  31, 39,  77, 

79,  84,  108,  109,  136,  144,  208,  217-219. 
Postgraduate  Medical  College  and  Hospi- 
tal, 215. 

Valparaiso  University,  Chicago  College  of 
Medicine  and  Surgery,  39,  81,  82,  117, 
209,  216,  221. 
Illinois,  University  of,  College  of  Physicians  and 

Surgeons  (see  under  Illinois). 
Illinois  Medical  College  (see  under  Illinois). 
Illinois   Postgraduate   School  (tee  under  Illi- 
nois). 
Immigration  in  medical  schools,  38,  39. 


Indiana: 

Indiana  University,  28,  72,  75,  107,  119, 

148,  220. 

Valparaiso  University,  221. 
Indiana  University  (tee  under  Indiana). 
Infectious  diseases,  teaching  of,  117. 
Internal  medicine,  clinical  teaching  of,  92-96, 

106-124. 
Iowa: 

Drake  University,  117,  121,  222,  225. 

State  University  of  Iowa,  28,  72,  107,  135, 

149,  159,  223-225. 

Still  College  of  Osteopathy,  165,  223. 
Iowa,  State  University  of  (tee  under  Iowa). 

JEFFERSON  Medical  College  (tee  under  Pennsyl- 
vania). 

Jenner  Medical  College  (tee  under  Illinois). 
Johns  Hopkins  University  (tee  under  Maryland). 
Jordan,  E.  O.,  59  (note). 

KANSAS  : 

University  of  Kansas,  28,  72,  73,  114,  116- 

119,  122,  149,  226. 

Washburn  College,  Kansas  Medical  Col- 
lege, 10,  88,  116,  118,  141,  227. 
Western  Eclectic  College  of  Medicine  and 

Surgery,  11,  122,  227. 
Kansas,  University  of  (tee  under  Kansas). 
Kansas  City  Hahnemann  Medical  College  (tee 

under  Missouri). 
Kansas  City  Hospital,  6. 
Kansas  Medical  College,  Washburn   College 

(see  under  Kansas). 
Kentucky : 

University    of   Louisville,    34,    84,    115, 

229-231. 

Louisville  National  Medical  College,  230. 
Southwestern  Homeopathic  Medical  Col- 
lege, 161,  230. 

Knoxville  Medical  College  (tee  tMwfcrTennessee). 
Kuhn,  Adam,  4. 

LABORATORY  branches  of  medical  instruction, 

71. 

Laboratory  equipment,  85,  86. 
Laboratory  instruction,  establishment  of,  11. 
Laval  University,  Montreal  (tee  under  Quebec). 
Laval  University,  Quebec  (tee  under  Quebec), 
Leland  Stanford  Junior  University  («w  under 

California).  [olina). 

Leonard  Medical  College  (tee  under  North  Car- 


342 


INDEX 


Lexis,  W.,  93  (note). 

Libraries  at  medical  schools,  82. 

Licensure,  examination  for,  169. 

Lincoln  Medical  College  (see  under  Nebraska). 

Lincoln  Memorial  University,  Tennessee  Med- 
ical College  (tee  under  Tennessee). 

Littlejohn  College  of  Osteopathy  (see  under  Illi- 
nois). 

Long  Island  College  Hospital  (see  under  New 
York). 

Los  Angeles  College  of  Osteopathy  (see  under 
California). 

Louisiana : 

Flint  Medical  College,  181,  232. 
Tulane  University,  30,  41,  77,  79,  82,  111, 
135,  142,  148,  231,  233. 

Louisville,  University  of  (see  under  Kentucky). 

Louisville  National  Medical  College  (see  under 
Kentucky). 

MAINE: 

Bowdoin  College,  Medical  School  of  Maine, 
31,81, 116, 119,  122-124,138, 147, 170,233. 
Manhattan  Eye,  Ear,  and  Throat  Hospital 
Postgraduate    School    (see  under  New 
York). 
Manitoba : 

University  of  Manitoba,  108,  150,  320,  326. 
Manitoba,  University  of  (see  under  Manitoba). 
Marquette  University  (see  under  Wisconsin). 
Maryland : 

Atlantic  Medical  College,  39, 160,  161,  237, 

239. 

Baltimore  Medical  College,  39,  81,  236. 

Johns  Hopkins  University,  11,  12,  28,  37, 

38,  72,  76,  79,  83,  85,  100,  106,  107,  111, 

115,  121,  133,  134,  142,  143,  178,  234,  239. 

University  of  Maryland,  5,  38,  39,  43,  80- 

84,  107,  136,  236,  239. 
Maryland  Medical  College,  10,  39,  87,  237. 
College  of  Physicians  and  Surgeons,  Balti- 
more, 39,  80-82,  84,  85,  107,  136,  235,  239, 
317.  [118,  237. 

Woman's  Medical  College  of  Baltimore,  10, 
Maryland,  University  of  (see  under  Maryland). 
Maryland  Medical  College  (see  under  Maryland). 
Massachusetts : 

Boston  University,  31, 82, 121, 138, 159-161, 

241. 

Harvard  University,  5,  7-9,  11.  12,  28,  29, 
32,  38,  43,  47,  72,  76,  81,  109,  110,  121, 
134,  142,  144,  147,  151,  172,  240,  263. 


Massachusetts  (continuf<l)  •. 

Massachusetts  College  of  Osteopathy,  164, 

242. 

College  of  Physicians  and  Surgeons,  Bos- 
ton, 81,  120,  172,  242,  262. 
Tufts  College,  7,  31,  33,  37-39, 109,  110,  116, 

121,  136,  144,  151,  263. 
Massachusetts  College  of  Osteopathy  (see  under 

Massachusetts). 

Massachusetts  General  Hospital,  5. 
McDowell,  Ephraim,  15. 
McGill  University  (see  under  Quebec). 
Medical  College  of  the  State  of  South  Carolina 

(see  under  South  Carolina). 
Medical  College  of  Virginia  (see  under  Virginia). 
Medicine  and  Surgery,  College  of,  Oakland, 

California  (see  under  California). 
Medicine  and  Surgery:  Physio-Medical,  Col- 
lege of,  Chicago,  Illinois  (see  under  Illinois). 
Medical  School  of  Maine,  Bowdoin  College  (see 

under  Maine). 

Medical  work  in  college  course,  29. 
Medico-Chirurgical  College  of  Philadelphia  (see 

under  Pennsylvania). 
Meharry  Medical  College,  Walden  University 

(see  under  Tennessee). 
Memphis,  University  of,  College  of  Physicians 

and  Surgeons  (see  under  Tennessee). 
Memphis  Hospital  Medical  College  (see  under 

Tennessee). 

Mexico,  University  of,  3  (note). 
Michigan : 

American  Medical  Missionary  College,  119, 
211,  244.  [245,  246. 

Detroit  College  of  Medicine,  35,  86,  117, 
Detroit  Homeopathic  College,  122, 161, 246. 
University  of  Michigan,  21,  28,  29,  32,  37, 
39,  72,  74,  78,  100,  106,  109,  111,  119,  128, 
134,  135,  159,  160,  243,  244,  282. 
Michigan,  University  of  (see  under  Michigan). 
Minnesota : 

University  of  Minnesota,  28,  37,  38,  43,  47, 

51,  72,  78,  85,  107,  112,  134,  247. 
Minnesota,  University  of  (see  under  Minnesota). 
Mississippi : 

University  of  Mississippi,  73,  249. 
Mississippi  Medical  College,  10,  36,  39,  86, 

87,  120,  123,  178,  249. 

Mississippi,  University  of  (see  under  M  ississippi ). 
Mississippi  Medical  College  (see  under  Missis- 
sippi). 


INDEX 


343 


Missouri : 

American  College  of  Osteopathy,  119,  140, 

253. 

American  Medical  College,  11,  87,  123,  257. 
Barnes  Medical  College,  11,  81,  88,  109, 

122,  256. 

Central  College  of  Osteopathy,  87,  252. 
Ensworth  Medical  College,  10,  82,  123,  254. 
Hippocratean  College  of  Medicine,  86,  119, 

257. 
Kansas  City  Hahnemann  Medical  College, 

83,  252. 

Postgraduate  Hospital  School,  258. 
University  of  Missouri,  28,  37,  72,  75,  251. 
St.  Louis  College  of  Physicians  and  Sur- 
geons, 11,  86,  88,  115,  118,  122,  140,  256, 

258,  259. 
St.  Louis  University,  78,  79,  112,  114,  115, 

255,  258,  259. 
University  Medical  College,  87,  109,  117, 

251. 
Washington  University,  106,  108,  111,  135, 

254,  258. 

Missouri,  University  of  (see  under  Missouri). 
Morgan,  John,  4. 

"Mortality"  in  medical  schools,  37,  38. 
Museums  at  medical  schools,  82. 

NUMBER  of  physicians,  13-18,  147-151. 
Nashville  and  Tennessee  Medical  Department, 

Universities  of  (see  under  Tennessee). 
National  Medical  University  (see  under  Illinois). 
Navy  Medical  School,  Washington,  D.  C.  (see 

under  District  of  Columbia). 
Nebraska : 

John  A.  Creighton  Medical  College,  22,  31, 
32,  80,  81,  83,  85,  88,  114,  116,  118,  151, 
260,  261. 
Lincoln  Medical  College,  12,  86,  120,  123, 

141,  260. 
University  of  Nebraska,  28,   72,  73,  113, 

119,  149,  151,  259. 

Nebraska,  University  of  (see  under  Nebraska). 
Negro,  Medical  schools  for  the,  180,  181. 
New  England,  medical  instruction  in,  261. 
New  England,  number  of  doctors  needed,  147. 
New  Hampshire : 

Dartmouth  College,  5,  39,  72,  116,  118,  123, 

124,  147,  170,  263,  264. 
New  York : 

Brooklyn  Postgraduate  Medical  School,  8, 
132,  176,  273. 


New  York  (continued) : 

University  of  Buffalo,  5, 19,  37,  39,  82,  1 14, 
123,  125,  138,  267. 

Columbia  University,  College  of  Physicians 
and  Surgeons,  5,  8,  9,  11,  21,  32,  47,  72, 
74,  76,  84,  107-110,  112,  115,  121,  131, 

134,  268,  275,  276. 

Cornell  University,  28,  29,  37,  47,  72,  75, 
76,  84,  109,  110,  115,  119,  121,  131,  134, 
178,  268,  275-27T. 

Eclectic  Medical  College,  New  York,  11, 
86,  87,  117,  122,  271. 

Fordham  University,  28,  115,  270. 

Long  Island  College  Hospital,  39,  80,  82, 
121,  125,  138,  266. 

Manhattan  Eye,  Ear,  and  Throat  Postgra- 
duate School,  274. 

New  York  Homeopathic  College  and  Hos- 
pital, 159-161,  272. 

New  York  Medical  College  and  Hospital 
for  Women,  115,  117,  160,  271. 

New  York  Polyclinic  Medical  School  and 
Hospital,  174,  175,  274. 

New  York  Postgraduate  School,  175,  273. 

New  York  University,  University  and  Belle- 
vue  Hospital  Medical  College,  11, 38,  39, 
79,  90,  109,  110,  121,  125,  126,  131,  134, 

135,  269,  275-277. 

Syracuse  University,  28,  72,  79,  122,  137, 

272,  276. 

Union  University,  Albany  Medical  College, 

13,  80,  82,  112,  118,  121, 125,  138, 141,  265. 

New  York  Homeopathic  College  and  Hospital 

(see  under  New  York). 
New  York  Medical  College  and  Hospital  for 

Women  (tee  under  New  York). 
New  York  Polyclinic  Medical  School  and  Hos- 
pital (tee  under  New  York). 
New  York  Postgraduate  School  (tee  under  New 

York). 

New  York  University,  University  and  Bellevue 
Hospital  Medical  College  (tee  undtr   New 
York). 
North  Carolina : 

Leonard  Medical  College,  Shaw  Univer- 
sity, 138,  181,  280. 

University  of  North  Carolina,  28,  279. 
North  Carolina  Medical  College,  7,  22,  87, 

279. 

Wake  Forest  College,  72,  85,  280. 
North  Carolina,  University  of  (tee  under  North 
Carolina). 


344 


INDEX 


North    Carolina  Medical  College    (tee    under 

North  Carolina). 

North  Dakota:  [282. 

State  University  of  North  Dakota,  28,  72, 

North  Dakota,  State  University  of  (tee  under 

North  Dakota). 

Northwestern  University  (tee  under  Illinois). 
Nova  Scotia : 

Dalhousie  University,  Halifax  Medical  Col- 
lege, 19,  86,  88,  122,  139,  141,  150,  170, 
320,  321,  325. 
Number  of  medical  schools,  6. 

OBSTETRICS,  teaching  of,  117. 
Ohio: 

University  of  Cincinnati,  Ohio-Miami  Med- 
ical College,  7,  283,  288,  289. 

Cleveland  Homeopathic   Medical  College, 

122,  285. 

Eclectic  Medical  Institute,  11,  283. 

Pulte  Medical  College,  87,   140,  159-161, 

284. 
Starling-Ohio  Medical  College,  22,  81,  114, 

117,  118,  122,  136,  286,  288. 
Toledo  Medical  College,  5, 81,  86,  112,  115, 

140,  287. 

Western  Reserve  University,  28,  29,  47,  72, 
76,  90,  106,  108,  121,  126,  128,  151,  278, 
285,  288. 

Ohio-Miami  Medical  College,  University  of  Cin- 
cinnati (see  under  Ohio). 
Oklahoma : 

Epworth  University,  12,  117, 123,  141,  290. 
State  University  of  Oklahoma,  86, 149, 151, 

289. 

Oklahoma,  State  University  of  (see  under  Okla- 
homa). 
Ontario : 

Queen's  University,  39,  322. 
University  of  Toronto,  15,  30,  38,  41,  43, 
77-79,  108,  134,  150,  170,  178,  250,  282, 
323,  325,  326. 
Western  University,  12,  13, 19,  35,  86, 117, 

123,  141,  150,  170,  322,  325. 
Oregon : 

University  of  Oregon,  39,  81,  84,  87,  122, 

139,  141,  151,  291. 
Willamette  University,  12,  86, 87,  118,  120, 

123,  140,  292. 

Oregon,  University  of  (tee  under  Oregon). 
Osier,  Wm.,  64,  95. 
Osteopathic  medical  sect,  158,  163-166,  172. 


PACIFIC  College  of  Osteopathy  (tee  under  Cali- 
fornia). 

Pathology,  59,  60,  65-67,  75,  84. 
Paulsen,  Professor,  14,  130. 
Pearce,  R.  M.,  84. 
Pennsylvania : 

Hahnemann  Medical  College  and  Hospital, 

82,  113,  139,  159-161,  295. 
Jefferson  Medical  College,  21,  30,  38,  39, 

77,  79,  82,  107,  135,  136,  151,  294,  299. 
Medico-Chirurgical    College  of   Philadel- 
phia, 21,  37-39,  80-83,  85,  90,  107,  126, 
294. 

University  of  Pennsylvania,  5, 8,  21, 28,  29, 
31,  38,  39,  72,  83,  107,  111,  151,  293,  299, 
300. 

Philadelphia  College  and  Infirmary  of  Os- 
teopathy, 88,  120,  164,  296. 
Philadelphia  Polyclinic,  298. 
University  of  Pittsburgh,  22,  137,  297,  300. 
Temple  University,  81,  86,  88,  117,  295. 
Woman's  Medical  College  of  Pennsylvania, 

112,  117,  296. 

Pennsylvania,  University  of  (see  under  Pennsyl- 
vania). 

Pharmacology,  63-65. 
Philadelphia,  College  of,  4,  5 
Philadelphia  College  and  Infirmary  of  Osteo- 
pathy (see  under  Pennsylvania). 
Philadelphia    Polyclinic    (see  under    Pennsyl- 
vania). 
Physicians  and  Surgeons,  Baltimore,  Maryland, 

College  of  (see  under  Maryland). 
Physicians  and  Surgeons,  Boston,  Massachu- 
setts, College  of  (see  under  Massachusetts). 
Physicians  and  Surgeons,  Columbia  University, 

College  of  (see  under  New  York). 
Physicians  and  Surgeons,  Little  Rock,  Arkan- 
sas, College  of  (see  under  Arkansas). 
Physicians  and  Surgeons,  Los  Angeles,  Califor- 
nia, College  of  (see  under  California). 
Physicians  and  Surgeons,  San  Francisco,  Cali- 
fornia, College  of  (see  under  California). 
Physicians  and  Surgeons,  University  of  Illinois, 

College  of  (see  under  Illinois). 
Physicians  and  Surgeons,  University  of  Mem- 
phis, College  of  (see  under  Tennessee).       [26. 
Physics,  teaching  of,  in  medical  education,  25, 
Physiology,  58,  59,  62,  63. 
Physio-medical  sect,  158.  [vania). 

Pittsburgh,  University  of  (tee  under  Pennsyl- 


INDEX 


345 


Postgraduate  Hospital  School,  Kansas  City, 

Missouri  (see  under  Missouri). 
Postgraduate  Medical  College  and  Hospital, 

Chicago,  Illinois  (see  under  Illinois). 
Postgraduate  medical  schools,  174-177. 
Pre-medical  college  course,  74. 
Promotion  of  students,  37. 
Proprietary  schools,  5. 
Pulte  Medical  College  (see  under  Ohio). 

QUEBEC  : 

Laval  University,  Montreal,  35,  150,  325. 

Laval  University,  Quebec,  150,  324,  326. 

McGill  University,  15,  27,  38,  41,  43,  77-79, 
82,  108,  134,  150,  170,  250,  282,  324-326. 
Queen's  University  (see  under  Ontario). 
"Quiz-compends,"  21. 
Quiz-masters,  work  of,  84. 

REGISTRATION  offices  at  medical  schools,  31. 
Reliance  Medical  College  (see  under  Illinois). 
Roosevelt  Hospital,  New  York  City,  108,  112. 
Rush,  Benjamin,  4. 

Rush  Medical  College,  University  of  Chicago 
(tee  under  Illinois). 

ST.  Louis  College  of  Physicians  and  Surgeons 

(see  under  Missouri). 

St.  Louis  University  (see  under  Missouri). 
Schedule  of  studies  at  certain  medical  schools, 

90,  126. 

Scholarships  at  medical  schools,  43. 
Seattle,  resolutions  of  physicians  of,  against  a 

state  medical  school,  150. 
Sects,  medical,  156-166. 
Shippen,  William,  3,  4. 
Smith,  Nathan,  5. 
South  Carolina : 

Medical  College  of  the  State  of  South  Caro- 
lina, 81,  85,  123,  300. 
South  Carolina,  Medical  College  of  the  State 

(see  under  South  Carolina). 
South  Dakota : 

University  of  South  Dakota,  28,  72,  301. 
South  Dakota,  University  of  (see  under  South 

Dakota). 

Southern  Medical  College  Association,  39. 
Southwestern   Homeopathic    Medical  College 

(see  under  Kentucky). 

Southwestern  University  (see  under  Texas). 
Special  students,  28,  29,  39. 
Starling-Ohio  Medical  College  (see  under  Ohio). 
State  boards,  167-173. 


Stethoscope,  introduction  of,  8. 

Still  College  of  Osteopathy  (see  under  Iowa). 

Surgery,  teaching  of,  97,  116. 

Syracuse  University  (see  under  New  York). 

TEMPLE  University  (see  under  Pennsylvania). 
Tennessee : 

University  of  Chattanooga,  10,  19,  86,  123, 

139,  302. 

Knoxville  Medical  College,  303. 
Lincoln  Memorial   University,  Tennessee 
Medical  College,  10,  109,  118,  303,  3O8. 
Meharry  Medical  College  (see,  below,  Wai- 
den  University). 

University  of  Memphis,  College  of  Physi- 
cians and  Surgeons,  5,  7,  21,  88,  304. 
Memphis  Hospital  Medical  College,    10, 

124, 304. 

Universities  of  Nashville  and  Tennessee 
Medical  Department,  20, 88, 1 17, 1 18, 151, 
305,  308. 

University  of  West  Tennessee,  305. 
Vanderbilt  University,  31,  34,  36,  37,  40, 
41,  88,  136,  142,  148,  151,  305,  308,  309. 
Walden  University,  Meharry  Medical  Col- 
lege, 138,  148,  151,  181,  282,  305,  309. 
Tennessee  Medical  College,  Lincoln  Memorial 

University  (see  under  Tennessee). 
Tennessee  (and  of  Nashville)  Medical  Depart- 
ment, Universities  of  (see  under  Tennessee). 
Texas: 

Baylor  University,  81,  117,  141,  309. 
Fort  Worth  University  12,  39,  86,  310. 
Southwestern  University,  12,  86,  88,  114, 

117,  140,  310. 
University  of  Texas,  21,  31,  38,  41,  79,  81, 

82,  88,  107,  115,  119,  292,  311. 
Texas,  University  of  (see  under  Texas). 
Toledo  Medical  College  (see  under  Ohio). 
Toronto,  University  of  (see  under  Ontario). 
Transylvania  University,  5. 
Tufts  College  (see  under  Massachusetts). 
Tulane  University  (see  under  Louisiana). 

UNION  University,  Albany  Medical  College 
(see  under  New  York). 

University  and  Bellevue  Hospital  Medical  Col- 
lege, New  York  University  (see  under  New 
York). 

University  College  of  Medicine  (see  under  Vir- 
ginia). 

University  Medical  College  («w  under  Missouri). 


346 


INDEX 


University  of  West  Tennessee  (see  under  Ten- 
nessee), 
Utah: 

University  of  Utah,  28,  72,  313. 
Utah,  University  of  (tee  under  Utah). 

VALPARAISO  University,  Chicago  College  of 
Medicine  and  Surgery  (see  under  Illinois  and 
under  Indiana). 

Vanderbilt  University  (see  under  Tennessee). 

Vermont : 

University  of  Vermont,  31,  85,  116,  139, 

147,  262,  313. 

Vermont,  University  of  (see  under  Vermont). 
Virginia : 

Medical  College  of  Virginia,  82,  315. 

University  College  of  Medicine,  315,  316. 

University  of  Virginia,  28,  38,  100,  109,  111, 

148,  314,  316. 

Virginia,  University  of  (see  under  Virginia). 
Von  Strumpell,  90  (note). 

"WAKE  Forest  College  (see  under  North  Caro- 
lina). 

Walden  University,  Meharry  Medical  College 
(see  under  Tennessee). 

Wash  burn  College,  Kansas  Medical  School  (see 
under  Kansas). 

Washington  University  (see  under  Missouri). 


Welch,  William  H.,  11. 

Western  Eclectic  College  of  Medicine  and  Sur- 
gery (see  under  Kansas). 

Western  Reserve  University  (tee  under  Ohio). 
Western  University  (see  under  Ontario). 
West  Virginia : 

West  Virginia  University,  317. 
West  Virginia  University  (tee  under  West  Vir- 
ginia). 

Willamette  University  (see  under  Oregon). 
Wisconsin : 

Marquette  University,  Milwaukee  Medi- 
cal College,  39,  81,  86,  109,  114,  117,  118, 
318. 
University  of  Wisconsin,  28,  38,  72,  74,  75, 

135,  136,  148,  317. 

Wisconsin  College  of  Physicians  and  Sur- 
geons, 81,  83,  118.  318. 

Wisconsin,  University  of  (see  under  Wisconsin). 
Wisconsin  College  of  Physicians  and  Surgeons 

(see  under  Wisconsin). 
Women,  medical  education  of,  178,  179. 
Woman's   Medical  College  of  Baltimore  (see 

under  Maryland). 
Woman's    Medical    College   of  Pennsylvania 

(see  under  Pennsylvania). 
Wyeth,  John  A.,  174. 

YALE  University  (see  under  Connecticut). 


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